Sonographic imaging of mallet finger.

UNLABELLED: Mallet finger is a flexion deformity of the distal interphalangeal joint (DIPJ) caused by a disruption of the extensor mechanism. The deformity can b e caused by active trauma, minor trauma or other conditions like rheumatoid arthritis or osteoarthritis. AIM: To describe the sonographic findings in mallet finger. METHOD: We performed sonographic examination on thirty patients with traumatic mallet finger, on thirty control patients where we examined the same finger in the opposite hand (,) and thirty patients with rheumatoid arthritis or osteoarthritis and flexion deformity. RESULTS: We found four criteria for traumatic mallet finger which included: discontinuity of the extensor tendon with partial or complete tear, avulsion fracture, no real time movements of the extensor tendon, and fluid in the region of insertion of the extensor tendon. CONCLUSION: Sonographic examination of patients with traumatic mallet finger is an important diagnostic tool and can differentiate between traumatic mallet finger and flexion deformity of rheumatoid arthritis or osteoarthritis.

Fatal liver infarction after transjugular intrahepatic portosystemic shunt procedure.

Hepatic infarction is a rare disease. We describe here a cirrhotic patient with end-stage renal failure and recurrent tense ascites with fatal hepatic infarction after transjugular intrahepatic portosystemic shunt (TIPS) procedure. Abdominal ultrasound, radionuclide liver scan, abdominal computed tomography scan, and finally liver biopsy established the diagnosis. The mechanism causing the infarct is not clear. However, as the infarct appeared after the patient had an episode of shock and disseminated intravascular coagulation, it could well be that the concomitant hepatic arterial insufficiency contributed to the infarct. Physicians should be aware of this possible catastrophic complication.

Non-neoplastic intratesticular lesions mimicking tumour on ultrasound.

It has recently been emphasized that the incidence of benign testicular lesions is much higher than previously suspected. Sonography is reported to have a high sensitivity but poor specificity in the evaluation of intratesticular abnormalities. This report reviews the common and unusual lesions that can mimic testicular tumour on ultrasound, and discusses the clinical and sonographic features that may help to narrow the differential diagnosis and guide management.

The use of ultrasonography as a diagnostic tool for superficial fascial space infections.

PURPOSE: This study examined the value of ultrasonography as a diagnostic tool in the treatment of superficial acute odontogenic fascial space infections. PATIENTS AND METHODS: The study group consisted of 50 patients in whom both radiographic and sonographic examinations, as well as a needle aspiration, were performed. RESULTS: Purulent fluid was aspirated in 22 of the 50 patients. Six patients diagnosed as suffering from cellulitis had a repeated ultrasonography scan. In four, abscess formation was diagnosed on the third day. CONCLUSIONS: Ultrasonography is an effective diagnostic tool to confirm abscess formation in the superficial fascial spaces and is highly predictable in detecting the stage of infection.

Congenital aorto-caval fistula in the newborn: a case report.

The authors report a rare case of congenital fistula between the distal aspect of the descending aorta and the inferior vena cava. The clinical features of this aortocaval fistula is being described as well as the preoperative diagnostic workup, the intraoperative findings, and the complicated postoperative course and treatment.

Pyelocalyceal diverticula containing milk of calcium--CT diagnosis.

OBJECTIVE: To present the computed tomography (CT) findings of pyelocalyceal diverticula containing milk of calcium in seven patients. MATERIAL AND METHODS: Three patients were examined because of flank pain, one because a malignant lesion was suspected and the three others were examined for unrelated symptoms. Three repeated scans to the kidney area were performed in every patient: an unenhanced scan, post-contrast scan and a delayed scan. RESULTS: Unenhanced scans demonstrated an intraparenchymal round lesion with calcific material localized either at the inferior border or filling almost the entire cavity. On post-contrast scans a contrast-fluid level appeared, with some enhancement of the clear fluid in the upper part of the cyst. A further rise in the contrast-fluid level or total opacification with a density identical to that of the collecting system was obtained on delayed scans. CONCLUSION: Pyelocalyceal diverticula containing milk of calcium present on CT as a partially calcified renal mass. Slight opacification soon after injection may be mistaken for enhancement arousing suspicion of a tumour. However, a delayed scan will demonstrate a densely opacified cyst filled with contrast from the collecting system which is virtually pathognomonic of the lesion.

Role of renal ultrasonography in the management of pyelonephritis in pregnant women.

OBJECTIVE: The objective of this study was to determine the usefulness of renal ultrasonography in pregnant women with pyelonephritis. STUDY DESIGN: A retrospective review was done of hospital records of 171 consecutive pregnant women admitted to the hospital over a 7-year period with the diagnosis of pyelonephritis. RESULTS: Urine cultures were positive in all but one of the women and intravenous antibiotics were administered in all cases. Renal ultrasonography was done in 75 (43.9%) of the women and results found to be normal in 26 (34.7%) of them. The renal pelvis was dilated mildly (6 to 10 mm) in 25 (33.3%), moderately (11 to 15 mm) in 16 (21.3%), and severely (> or = 16 mm) in 8 (10.7%) patients. Duplicated collecting systems and renal calculi were each found in 2 (2.7%) patients. All patients were treated conservatively with no need for ureteral stents. Three of the patients with severe hydronephrosis were first seen at term and delivery was therefore induced. There was no difference in maternal characteristics and outcome of pregnancy between women who underwent renal ultrasonography and those who did not. However, the duration of hospitalization was significantly longer (p < 0.02) for women in whom renal ultrasonography was performed (mean +/- SD, 5.8 +/- 1.7 vs 4.1 +/- 1.3 days). CONCLUSION: Renal ultrasonography is of limited benefit in pregnant women with pyelonephritis, because these imaging studies only rarely modify management and do not significantly affect pregnancy outcome.

Chronic massive knee effusion in familial Mediterranean fever.

OBJECTIVE: To document the occurrence of chronic massive knee effusions in patients with familial Mediterranean fever (FMF). PATIENTS: Three cases of chronic massive knee effusion of young FMF patients requiring open synovectomy are presented. RESULTS: Open synovectomy necessitated protracted rehabilitation, eventually with good results. CONCLUSIONS: FMF should be considered in the differential diagnosis of chronic massive knee effusion. Early diagnosis and daily colchicine treatment generally result in a good clinical outcome and may eliminate the need for open synovectomy in favor of arthroscopic surgery.

Preoperative assessment of blood vessel involvement in patients with pancreatic cancer.

The major prerequisite for resection of a pancreatic tumor is non-involvement of large blood vessels. Preoperative assessment of blood vessel infiltration may prevent unnecessary surgery. The aim of our study was to investigate the accuracy of endoscopic ultrasonography (EUS) in diagnosis of pancreatic cancer and in preoperative staging. Thirteen patients (7 females, 6 males; mean age 64 years) with a pancreatic tumor, but no evidence of distant metastases, underwent EUS and computerized tomography (CT) in order to assess blood vessel involvement by the tumor. The results were compared with intraoperative findings in 12 patients and with postmortem findings in 1 patient. A tumor was demonstrated by EUS in 12 patients and was confirmed at surgery in all 12 patients. In one patient no tumor was demonstrated by EUS, although a tumor was visible by CT; no tumor was found at surgery. In two patients CT failed to demonstrate a pancreatic tumor that was demonstrated by EUS; at surgery a tumor was detected in both patients. EUS detected blood vessel involvement in seven patients, which was confirmed at surgery in six of them. In the other six patients surgery confirmed the EUS finding of no blood vessel involvement. CT detected blood vessel involvement in two patients only. The overall accuracy of EUS and CT for detecting the tumor was 100% and 77% respectively, and for blood vessel involvement 92% and 61% respectively. In conclusion, EUS is an accurate procedure for preoperative assessment of blood vessel involvement in patients with pancreatic cancer. This procedure may enable the selection of those patients who may benefit from surgery, and should be part of the evaluation of patients with pancreatic cancer who are candidates for curative surgery.

[Ultrasound-guided aspiration of pleural fluid].

We review the outcome of guided, percutaneous, catheter drainage of pleural collections in 102 patients over a 2-year period. In 87% diagnostic aspiration of small or loculated collections was performed. Drainage of malignant and nonmalignant effusions in high-risk patients, or after failure of drainage without imaging guidance, was performed in 13%. All aspirations were successful and the only complication was a small pneumothorax in a single patient. If the collection was a small pneumothorax in a single patient. If the collections were large and easy to aspirate, we marked the best location for aspiration on the skin and sent the patient back to the ward for aspiration. We conclude that the use of sonography increases the proportion of successful drainage of small pleural collections and results in few complications.

Correct preoperative localization: does it permit a change in operative strategy for primary hyperparathyroidism?

BACKGROUND: A meticulous bilateral neck exploration by an experienced endocrine surgeon offers a high cure rate with low morbidity for patients with primary hyperparathyroidism. The advent of localizing studies raises the possibility of unilateral neck exploration. The cost-effectiveness of preoperative localizing studies and unilateral neck exploration in primary hyperparathyroidism are controversial issues. This study was designed to determine the risks of missing a contralateral pathologic parathyroid gland in patients with preoperative localization that was confirmed at neck exploration. METHODS: Preoperative studies (ultrasonography, nuclear radioactive imaging scan, or both) were performed in 79 patients with primary hyperparathyroidism. In 58 patients a definite localization of an enlarged parathyroid gland was confirmed at operation. All patients underwent a meticulous bilateral neck exploration. RESULTS: Unilateral neck exploration was feasible only in 73.4% of the patients, according to our localizing modalities, and an additional enlarged parathyroid gland on the contralateral side, not detected before operation, was revealed in five patients (8.6%). False-positive rates were 1.7% for ultrasonography and 13% for scan. CONCLUSIONS: These results indicate an unacceptably high surgical failure rate for unilateral neck exploration guided by preoperative localizing studies compared with a bilateral neck exploration by an experienced endocrine surgeon, questioning the cost-effectiveness of preoperative localizing studies.

Ultrasonographic evaluation and clinical correlation of intratesticular lesions: a series of 39 cases.

OBJECTIVE: To assess the accuracy, specificity and sensitivity of ultrasonography (US) for diagnosing testicular tumours. PATIENTS AND METHODS: Ultrasonography of the scrotum was performed in 39 patients (mean age 20.3 years, range 3-61) referred to the hospital because of pain, tenderness, appearance of a mass in the scrotum or swelling of the scrotum after trauma. RESULTS: Intratesticular lesions were detected by US in 35 patients and four had no suspicious findings after surgical exploration of the scrotum based solely on clinical findings. In five patients the findings on US were compatible with neoplasm, but at surgery or follow-up, no tumour was found. In one case, the US findings suggested inflammation, but on exploration 3 weeks later, an embryonal cell carcinoma was found. CONCLUSIONS: While very sensitive in differentiating an intra-from an extratesticular lesion, and in ruling out a testicular tumour (sensitivity 96.6%), the US examination is less specific (specificity 44.4%) as the US pattern of different benign process may be similar to those of tumours. The positive predictive value (85.3%) and the accuracy (84.6%) imply that when an intratesticular lesion is detected on US, even when there is no clinical suspicion of neoplasm, exploration of the scrotum is indicated.

Accuracy of endoscopic ultrasonography for preoperative staging of esophageal malignancy.

Surgery for esophageal cancer carries a high mortality rate and a low rate of resectability for cure. Accurate preoperative staging is therefore of utmost importance. Staging is based on computerized tomography (CT), and recently, the use of endoscopic ultrasonography (EUS). We performed EUS and CT on 10 patients with esophageal cancer. Tumors were staged according to the TNM classification. According to the CT results, seven patients had a T3 tumor, one T1-2 and two T0. All patients were diagnosed as T3 by EUS. One patient, who was treated by combined modality treatment with chemotherapy and radiotherapy, converted to T0. Six patients were operated on, and in five, pathological findings were of an invasive tumor. The T stage was predicted correctly in five patients by CT and in all six patients by EUS. N stage was correctly diagnosed in two patients by CT and in five by EUS. It is concluded that EUS is superior to CT for preoperative staging of esophageal tumors. EUS should be undertaken as a routine procedure prior to surgery for esophageal cancer.

The impact of fetal screening on indications for cystourethrography in infants.

To evaluate cystourethrography in the era of fetal screening, we evaluated retrospectively the clinical and imaging findings of all children up to the age of 1 year who underwent a cystourethrogram in a 5-year period (1987-1992). There were 292 children, 64 neonates (< 1 month, 51 boys, 13 girls) and 228 infants (1 month-1 year, 111 boys, 117 girls). Hydronephrosis detected prenatally and confirmed after birth by US was the indication for cystourethrography in 88 children (72 boys, 16 girls). This 4.5 to 1, male to female ratio is very unusual compared to children with urinary tract infection, the great majority of whom are girls. The findings based on imaging studies in these 88 children with hydronephrosis included 31 with vesicoureteral reflux (VUR) (in 4 this was secondary), 23 with obstruction at the ureteropelvic junction (UPJ), 13 with multicystic dysplastic kidney, 2 with obstruction at the ureterovesical junction, 1 with ectopic ureterocele and 1 with posterior urethral valves, both the latter without reflux. Eleven children had normal postnatal studies and six children were lost to follow-up. Urinary tract infection (UTI) was the indication in 163 children (62 boys, 101 girls). Forty-one children were examined for other causes. Although most cases of hydronephrosis were detected on fetal screening, UTI was still the most common indication for cystourethrography and some significant abnormalities were found in these symptomatic children.

Fetal intracranial haemorrhage: clinical significance of in utero ultrasonographic diagnosis.

OBJECTIVE: To review in utero detection of fetal intracranial haemorrhage. DESIGN: Retrospective survey of pregnant women presenting to the ultrasonographic unit in whom the diagnosis of fetal intracranial haemorrhage was reached. SETTING: The Chaim Sheba Medical Center in Ramat Gan, and Shaare Zedek Medical Center in Jerusalem; two large district general hospitals, each with 6000 maternity patients per year. SUBJECTS: Five fetuses with gestational ages ranging from 26 to 36 weeks. MAIN OUTCOME MEASURES: Maternal complications, fetal monitoring, prenatal Doppler ultrasound studies, postnatal imaging studies, neonatal morbidity and mortality. RESULTS: Transabdominal sonography showed hyperechoic lesions in the brain parenchyma, and the lateral ventricle in three of five fetuses. In the remaining two fetuses, transvaginal sonography enhanced the visualisation of ventriculomegaly with intraventricular haemorrhage in one and periventricular leukomalacia was identified in the second. Three fetuses were appropriate for gestational age, and two were severely growth retarded. In one woman severe pre-eclamptic toxaemia may explain intracranial haemorrhage. Abnormal nonstress test and abnormal flow velocity waveforms in the umbilical and cerebral arteries were present in the two growth retarded fetuses, and in one who was appropriate for gestational age. The two growth retarded fetuses died shortly after birth. Of the three surviving infants, two had normal long term development, and one developed hydrocephalus with subsequent severe neurodevelopmental retardation, dying at the age of seven months. CONCLUSIONS: This small series shows that intracranial haemorrhage has a broad spectrum of manifestations with diverse prognosis. Following an antenatal diagnosis of intracranial haemorrhage, the obstetrician must give special consideration to electronic fetal heart monitoring and Doppler velocity waveforms. The prenatal diagnosis of intracranial haemorrhage has medico-legal implications suggesting that neurological outcome may not necessarily be due solely to intrapartum events and management.