Pseudo-Volkmann's contracture due to tethering of flexor digitorum profundus to fractures of the ulna in children.

We studied seven children with the unusual complication of pseudo-Volkmann's contracture due to tethering of the flexor digitorum profundus to fractures of the ulna. It was detected 2 days to 16 years after closed reductions of fractures of the shafts of the radius and ulna. The children did not have nerve palsies or undue pain after the reductions. Normal length, excursion, and function of the flexor digitorum profundus was restored by untethering the muscle and its tendons from the ulnar fracture by early manipulation or by late localized myotenolysis. We recommend that the passive range of motion of all fingers be routinely checked immediately after closed reductions of fractures of the radius and ulna. If muscle tethering is detected, the fracture is remanipulated to release the muscle. If the muscle is still tethered, then surgical release, through a small incision, is required.

Early radiographic joint space narrowing and erosion and later malalignment in rheumatoid arthritis: a longitudinal analysis.

OBJECTIVE: To analyze the time course of development of radiographic erosion, joint space narrowing, and malalignment in a longitudinal study of radiographs of the hands and wrists of 58 patients with rheumatoid arthritis (RA) taken over 18 years. METHODS: Among 210 consecutive patients in a reported cohort, 58 had at least one prior available radiograph 2-18 years earlier. A total of 141 hand and wrist radiographs in the 58 patients were scored for joint space narrowing, erosion, and malalignment in individual joints. RESULTS: Of the 58 patients studied, all developed joint space narrowing, 56 (96.5%) developed erosions, while only 24 (41.4%) developed malalignment. In radiographs of 22 patient studied within the first 5 years of disease, joint space narrowing was seen in 17 (77.3%), erosion in 16 (72.7%), and malalignment in only 3 (13.6%). Radiographic progression was seen in all 36 patients in whom the interval between radiographs was longer than 2 years. CONCLUSION: Joint space narrowing and erosion are seen in hand radiographs of most patients with RA seen in treatment centers within the first 5 years of disease. By contrast, malalignment develops in fewer patients, and generally only after 5 years of disease.

Measures of activity and damage in rheumatoid arthritis: depiction of changes and prediction of mortality over five years.

OBJECTIVE: To analyze various quantitative measures of inflammatory activity and joint damage, including articular, radiographic, laboratory, questionnaire, and physical function measures, in regard to changes in status in surviving patients and prediction of mortality in non-survivors over 5 years in a cohort of patients with rheumatoid arthritis (RA) monitored in the mid-1980s and early 1990s. METHODS: A comprehensive evaluation, which included a complete joint count, radiograph, laboratory tests, physical measures of function, and self-report questionnaire scales, was performed at baseline and 5 years later in 210 consecutive patients with RA. RESULTS: Five years after baseline, 206 of the 210 patients were accounted for: 37 had died, 130 had a comprehensive repeat assessment, and 39 had a more limited repeat assessment. In surviving patients, most measures of activity were generally unchanged or somewhat better, including joint tenderness, pain on motion, and swelling; erythrocyte sedimentation rate and rheumatoid factor; as well as questionnaire scores for pain, global status, helplessness, and difficulty in performing 8 activities of daily living (ADL) according to a modified Health Assessment Questionnaire (MHAQ). By contrast, measures of damage, including joint deformity, grip strength, walk time, and radiographic scores, indicated worse status. Mortality over 5 years was predicted significantly in univariable analyses by American College of Rheumatology (formerly the American Rheumatism Association) Functional Class, limited joint motion, scores for MHAQ, global status, helplessness, grip strength, walk time, button time, and number of comorbidities and duration of diseases, as well as the sociodemographic measures of age and formal education. In multivariable Cox regressions, age, comorbidities, MHAQ, and other measures of functional status were the most effective predictors of 5-year mortality. CONCLUSION: In patients with RA, most measures of inflammatory activity were unchanged and sometimes better, while measures of damage indicated worse status in the same patients over 5 years. Measures indicating functional disability, as well as age and comorbidities, predict 5-year mortality more effectively than radiographic and laboratory data. Measures of inflammatory activity may underestimate long-term outcomes in RA, and long-term studies should include measures of damage.

Longitudinal stress fractures of the tibia: diagnosis by magnetic resonance imaging.

OBJECTIVE: Previous works describe magnetic resonance (MR) imaging characteristics of stress fractures. Diagnosis of the atypical, longitudinal type of stress fracture has been reported using computed tomography (CT). This report focuses on MR imaging of longitudinal stress fractures of the tibia. MATERIALS AND METHODS: Six cases are presented in which a longitudinal linear abnormal marrow signal was detected in the middle and distal parts of the tibial shaft. Five patients were imaged using a 1.5 Tesla MR unit. Axial, sagittal and coronal T1 and T2-weighted or fat suppressed proton density fast spin echo images were obtained in all but one patient. One patient was imaged using a 0.5 Tesla MR unit with axial and coronal T1- and T2-weighted sequences. Initial conventional radiographs seen at clinical presentation were interpreted as normal in all cases. Two patients underwent radionuclide bone scan. and one patient was imaged with CT prior to MR imaging. RESULTS: In each instance, MR imaging demonstrated linear marrow signal abnormalities orientated along the long axis of the tibial shaft. Endosteal and periosteal callus was identified on axial images. In all cases, MR imaging clearly demonstrated a fracture extending through one cortex with abnormal signal in both the marrow cavity as well as adjacent soft tissues indicating edema. CONCLUSION: MR imaging was shown to be excellent for demonstration of fracture lines, callus, and marrow and soft tissue abnormalities seen in association with longitudinal stress fractures.

Blunt needle infusion of local anesthetics or narcotic analgesics into operative wounds or joints.

Local anesthetics or narcotic analgesics introduced into surgical wounds have been noted to provide pain relief. These agents are typically infused into the postoperative joint or wound using a standard beveled needle or by pressing the syringe hub against the incision without a needle. We present an alternative method of administering these agents to provide pain relief in the orthopedic patient. A blunt needle is used to infiltrate the postoperative joint or wound with local anesthetics or narcotic analgesics.

Radiographic assessment of rheumatoid arthritis.

In this article, the rationale for the use of radiographs in the assessment of patients with rheumatoid arthritis is presented, along with a discussion of the choice of radiographs to be used. The author's choices for the scoring methods best used for minimal, intermediate, and more comprehensive databases for use in clinical research, other available scoring methods, factors influencing the type of database to be employed, and prior applications of scoring methods are also discussed.

Magnetic resonance imaging of the knee. A senior musculoskeletal radiologist's perspective.

After a brief review of the historical development of knee arthrography and MR imaging of the knee, the author concludes that MR imaging has become widely accepted as the imaging method of choice by both radiologists and nonradiologists. The author examines the current relative shortcomings and future developments of MR imaging of the knee.

Radiologic assessment of osteoarthritis. New techniques.

Of the newer imaging techniques, magnetic resonance imaging holds promise for earlier detection of features of osteoarthritis (OA). Computed tomography, bone scanning, and ultrasound play very limited roles in evaluation of OA. This article illustrates the uses of magnetic resonance imaging in the detection of OA.

MR imaging of deferoxamine-induced bone dysplasia in an 8-year-old female with thalassemia major.

Bone changes in thalassemic patients receiving deferoxamine therapy for iron chelation include metaphyseal and growth plate irregularities. We present a case of an 8-year-old female with thalassemia major, who had magnetic resonance imaging after plain radiographs had shown metaphyseal changes in the distal femur. The signal characteristics of these abnormalities were consistent with hyaline cartilage; the surrounding marrow showed no evidence of iron overload.

Imaging of disorders of the spine.

Although many papers were published during the past year on disorders of the spine, in this review, papers were chosen and grouped under five broad headings: 1) spinal trauma, 2) disk disease, 3) neoplastic disease, 4) spinal arthritis, and 5) other studies of interest. Although some of the articles chosen for review dealt with conventional radiography, the majority were on applications of CT and MR imaging to conditions affecting the spine.

Radiographic methods of assessment (scoring) of rheumatic disease.

The major features of various global and detailed methods of assessment (scoring) of the hands and wrists of patients with rheumatoid arthritis are reviewed. Relative advantages and disadvantages of the methods are presented. Detailed radiographic scores relate best to other measures of patient status. Although scoring is not a difficult skill, the work is tiring, tedious, and time-consuming. Quantitative methods have done much to further our understanding of rheumatoid arthritis; they hold the promise of further discoveries.

Arthritis: roles of radiography and other imaging techniques in evaluation.

Imaging studies are performed on patients with arthritis for a variety of reasons: to determine whether an arthritic condition is present; to establish the specific diagnosis; to determine the extent of disease; to assess the activity of disease; to detect complications of disease; to evaluate progression of disease; to judge the efficacy of drug treatment; to help in selection of surgical candidates; to aid in the choice of surgical procedures; to size, design, or fabricate prostheses; and to identify complications of surgery. Conventional radiography is still the mainstay of all examinations in arthritic patients. Arthrography is best applied to evaluate complications of disease and of surgery, although it may be useful in disease detection and in determining the specific diagnosis. Nuclear medicine studies are best used to identify complications of surgery and may also be useful to assess disease activity or extent. Ultrasound is useful to detect dissecting synovial cysts and deep venous thrombosis. The most valuable role of computed tomography is in the design and fabrication of prostheses and in evaluating complex anatomy of involved joints. Magnetic resonance imaging may be useful in early detection of articular cartilage damage and may assist in determination of the specific diagnosis; enhancement with contrast material may aid in assessment of disease activity.

Subchondral lucencies and synovial disease: a case report and discussion.

The case of a young female with hip pain and acetabular subchondral lucencies on conventional radiographs is presented. Computed tomography (CT) demonstrated subchondral lucencies in the femoral head as well, and an arthrogram revealed synovial irregularities. The differential diagnosis is discussed with an approach to subchondral lucencies. A synovectomy was performed on this patient with pigmented villonodular synovitis.

Cervical spine trauma.

The conventional radiographic examination remains as the single best initial study in patients with potential cervical spine injury. Computed tomography is the best, most readily available second study. Specific cervical spine injuries are presented as they follow a classification based on mechanism of injury.

Problems with the Steinbrocker staging system for radiographic assessment of the rheumatoid hand and wrist.

Hand and wrist radiographs of 202 patients with rheumatoid arthritis were graded with the classical Steinbrocker Staging System, and were also assigned quantitative scores for joint space narrowing, erosion, and malalignment according to a detailed scoring method. Steinbrocker Stage scores were correlated significantly with total detailed scores (r = 0.60 to 0.66, P less than 0.001). However, the ranges of detailed total and subtotal scores among the various Steinbrocker Stage scores were broad, with considerable overlap. Practical problems in applying the Steinbrocker staging method were identified in 26.5% of the hands graded with the Steinbrocker method. Additionally, analysis of scoring data showed discrepancies between the scoring methods in 25.2% of the hands examined; one-half of these discrepancies were felt to result from the global or overall approach of the Steinbrocker method in contrast to individual joint analysis. Asymmetry in assigned stages between right and left hands was found in 15.8% of patients. The detailed scoring method, although more time-consuming, appears superior to the Steinbrocker Stage for quantitative assessment of patient radiographic status in rheumatoid arthritis.

Thoracic and lumbar spine trauma.

The frequency and distribution of fractures of the thoracic and lumbar spine are reviewed. Classifications of thoracolumbar spine injuries are considered. Compression or wedge fractures, burst fractures, lap seat-belt-type injuries, and fracture-dislocations are considered with discussion of findings on conventional radiography and computed tomography. The concepts of stability and instability are briefly discussed and the relative advantages of computed tomographic imaging are reviewed.