Ultrasonography of the pediatric elbow.

Ultrasound of the elbow can be incorporated into routine pediatric practice in the radiology department, emergency department, orthopedic clinic, and interventional suite. Ultrasound is complementary to radiography and magnetic resonance imaging for the evaluation of elbow pain in athletes with overhead activities or valgus stress, focusing on the ulnar collateral ligament medially and capitellum laterally. As a primary imaging modality, ultrasound can be used for a variety of indications including inflammatory arthritis, fracture diagnosis, and ulnar neuritis/subluxation. Ultrasound is also well-suited to guide diagnostic and therapeutic elbow joint interventions with precise localization of anatomic landmarks and needle placement. Here, we describe technical aspects of elbow ultrasound and illustrate its application in pediatric patients from infants to teen athletes.

Non-contrast MRI diagnosis of adhesive capsulitis of the shoulder.

PURPOSE: To investigate non-contrast MRI findings of clinical adhesive capsulitis. METHODS: 31 non-contrast, non-arthrographic, shoulder MRIs were evaluated for coracohumeral ligament thickness, rotator interval infiltration, and axillary recess thickening/edema. RESULTS: In detection of adhesive capsulitis, sensitivity is 76.7% and specificity is 53.3% for coracohumeral ligament thickening, sensitivity is 66.7% and specificity is 55.2% for coracohumeral ligament thickening and rotator interval infiltration, and sensitivity is 23.3% and specificity is 86.7% for coracohumeral ligament thickening, rotator interval infiltration, and axillary recess thickening/edema. CONCLUSIONS: Adhesive capsulitis can be accurately diagnosed on non-contrast MRI shoulder examinations with appropriate clinical criteria without direct MR arthrography.

Resident Perspectives of an Interactive Case Review Following Independent Didactic Study as a Method of Teaching a Pediatric Imaging Curriculum.

PURPOSE: The ABR has recently changed the format of the board examination, in which the oral examination was replaced by a computer based multiple-choice test. The purpose of this study was to determine resident's perceptions of a new conference resembling the new ABR format. METHODS: Residents were requested to review a series of didactic pediatric imaging presentations prior to attending case conference. During conference, unknown cases reflecting the subject matter from the didactic presentations were presented along with multiple-choice questions. We then surveyed resident perspectives after each case conference. RESULTS: Between 14 and 18 residents were surveyed at the end of each subspecialty case review presentation. About 94% of resident respondents felt that the independent didactic study followed by an interactive case review session would better prepare them for the ABR certification exams, compared to didactic lectures alone. Furthermore, 95% of the respondents indicated that they preferred the independent didactic review followed by interactive case review versus didactic lecture alone. Most the respondents (85%) felt that combining independent didactic review with interactive unknown case sessions made the material more interesting and provided greater understanding of the material. There was no statistically significant difference in the distribution of answers across the subspecialty sessions (p > .05). CONCLUSION: Radiology residents favorably reviewed the combination of independent review of didactic material prior to interactive case review. Material presented in this fashion is felt to be more interesting and is thought to result in enhanced understanding of pediatric radiology material.

Association of Gluteus Medius and Minimus Muscle Atrophy and Fall-Related Hip Fracture in Older Individuals Using Computed Tomography.

PURPOSE: The aim of this study was to determine an association between fall-related hip and/or pelvic fractures and gluteus medius and minimus atrophy. METHODS: Retrospective review of 64 patients with fall-related hip/pelvic fractures and 96 age- and sex-stratified controls was performed. Gluteus medius, gluteus minimus, tensor fascia lata, and iliopsoas atrophy was scored using a standard scale. Statistical analysis was performed. RESULTS: There is a significant difference (P < 0.0001) in gluteus medius and minimus atrophy in the fracture versus control groups. Presence of gluteus atrophy was predictive of fall-related fracture (odds ratio, 2.15; 95% confidence interval, 1.08-4.31). There is no significant difference in tensor fascia lata (P = 0.47) or iliopsoas (P = 0.15) atrophy between the 2 groups. Gluteus atrophy increased with age (r = 0.41, P < 0.0001). In unilateral fractures, there is a significant difference (P = 0.0002) in ipsilateral versus contralateral gluteus medius atrophy. CONCLUSIONS: Gluteus medius and minimus muscle atrophy is greater in fall-related hip/pelvic fractures, which may predispose the elderly to falls.

ABR Core Examination Changes That Affect Residency Candidate Decisions.

PURPOSE: The recent restructuring of the ABR core examination has prompted changes to radiology residency training. The purpose of this study is to determine how factors related to the core examination restructuring influenced radiology applicants' match decisions. METHODS: We surveyed 626 applicants to our institution's radiology residency, after the 2014 match. Applicants rated 21 factors on a 5-point scale. Eight of the factors pertained to the core examination. The respondents additionally listed the top three factors in order of importance. RESULTS: The response rate was 153 of 626 (24.4%). The three most influential factors were current resident satisfaction (average score: 4.74 of 5.00 [95% confidence interval (CI) = 4.64-4.83]), quality of faculty (4.63 [95% CI = 4.52-4.73]) and quality of educational curriculum and clinical training (4.60 [95% CI = 4.50-4.70]). Of factors related to the core examination, the highest rated were core examination pass rate (4.21 [95% CI = 4.07-4.35]) and program resources/time off for external review courses (3.92 [95% CI = 3.79-4.04]). Core examination pass rate (16 of 459 [3.5%]) and time off from clinical duties to study for the examination (6 of 459 [1.3%]) appeared infrequently in respondents' lists of the top three most influential factors. CONCLUSIONS: Factors influencing candidates' choice of radiology program are similar to those reported previously, despite the addition of topics related to core examination restructuring. Although programs vary in how they have addressed the changes, these issues are less important to candidates than are more traditional factors.

Prevalence and pattern of gluteus medius and minimus tendon pathology and muscle atrophy in older individuals using MRI.

PURPOSE: To evaluate gluteus medius and minimus tendon pathology and muscle atrophy in older individuals using MRI. METHODS: A retrospective MRI study of 185 individuals was performed. The inclusion criterion was age ≥50. Exclusion criteria were hip surgery, fracture, infection, tumor, or inadequate image quality. Greater trochanteric bursitis was graded none, mild, moderate, or severe. Gluteus medius, gluteus minimus, and iliopsoas tendinopathy was graded normal, tendinosis, low-grade partial tear, high-grade partial tear, or full thickness tear. Gluteus medius, gluteus minimus, tensor fascia lata, and iliopsoas muscle atrophy was scored using a standard scale. Insertion site of tendinopathy and location of muscle atrophy were assessed. Descriptive and statistical analysis was performed. RESULTS: There was increasing greater trochanteric bursitis and gluteus medius and minimus tendinopathy and atrophy with advancing age with moderate to strong positive associations (p < 0.0001) for age and tendinopathy, age and atrophy, bursitis and tendinopathy, and tendinopathy and atrophy for the gluteus medius and minimus. There is a weak positive association (p < 0.0001) for age and tensor fascia lata atrophy, and no statistically significant association between age and tendinopathy or between age and atrophy for the iliopsoas. Fisher's exact tests were statistically significant (p < 0.0001) for insertion site of tendon pathology and location of muscle atrophy for the gluteus medius. CONCLUSIONS: Gluteus medius and minimus tendon pathology and muscle atrophy increase with advancing age with progression of tendinosis to low-grade tendon tears to high-grade tendon tears. There is an associated progression in atrophy of these muscles, which may be important in fall-related hip fractures.

Sonography of greater trochanteric pain syndrome and the rarity of primary bursitis.

OBJECTIVE: Greater trochanteric pain syndrome is a common condition with clinical features of pain and tenderness at the lateral aspect of the hip. Diagnosing the origin of greater trochanteric pain is important because the treatment varies depending on the cause. We hypothesized that sonographic evaluation of sources for greater trochanteric pain syndrome would show that bursitis was not the most commonly encountered abnormality. MATERIALS AND METHODS: We performed a retrospective review of musculoskeletal sonographic examinations performed at our institution over a 6-year period for greater trochanteric pain syndrome; completed a tabulation of the sonographic findings; and assessed the prevalence of trochanteric bursitis, gluteal tendon abnormalities, iliotibial band abnormalities, or a combination of findings. Prevalence of abnormal findings, associations of bursitis, gluteal tendinosis, gluteal tendon tears, and iliotibial band abnormalities were calculated. RESULTS: The final study population consisted of 877 unique patients: 602 women, 275 men; average age, 54 years; and age range, 15-87 years). Of the 877 patients with greater trochanteric pain, 700 (79.8%) did not have bursitis on ultrasound. A minority of patients (177, 20.2%) had trochanteric bursitis. Of the 877 patients with greater trochanteric pain, 438 (49.9%) had gluteal tendinosis, four (0.5%) had gluteal tendon tears, and 250 (28.5%) had a thickened iliotibial band. CONCLUSION: The cause of greater trochanteric pain syndrome is usually some combination of pathology involving the gluteus medius and gluteus minimus tendons as well as the iliotibial band. Bursitis is present in only the minority of patients. These findings have implications for treatment of this common condition.

Vertebroplasty and kyphoplasty in the United States: provider distribution and guidance method, 2001-2010.

OBJECTIVE: The purpose of this study was to determine the utilization by specialty and guidance method for vertebral augmentation (including vertebroplasty and kyphoplasty) in the United States from 2001 to 2010. MATERIALS AND METHODS: Using the 2001 through 2010 United States part B Medicare claims database, we studied the CPT-4 (Current Procedural Terminology, 4th ed.) codes used for thoracic (22520) and lumbar (22521) vertebroplasty, thoracic (22523) and lumbar (22524) kyphoplasty, and the method of radiologic guidance (76012 for fluoroscopy and 76013 for CT). For each of these codes, volume and physician specialty were tabulated. RESULTS: Radiologists performed 73% of Medicare-reimbursed vertebroplasty procedures in the United States in 2001-2010 and 30% of kyphoplasty procedures from 2006 to 2010. The majority were performed by nonradiologists, most notably orthopedic surgeons, who accounted for 40%. Although there was a decrease in utilization of vertebroplasty and kyphoplasty from 2009 to 2010, the number of vertebroplasties increased by 72.9% from 2001 to 2010, and the number of kyphoplasties increased by 12.0% from 2006 to 2010. Fluoroscopy is nearly universal as a guidance method for both vertebroplasty and kyphoplasty. CONCLUSION: This study shows that despite controversy regarding the long-term efficacy of vertebral augmentation, including vertebroplasty and kyphoplasty, utilization has risen since these procedures have been instituted and fluoroscopy is nearly universal as a guidance method. For vertebroplasty, the decrease in utilization from 2007 to 2009 may be explained in part by a combination of the initiation of kyphoplasty codes in 2006 and the August 2009 Kallmes et al. and Buchbinder et al. publications. Decreased utilization of both vertebroplasty and kyphoplasty from 2009 to 2010 may also be partly due to these publications.

Common sonographic findings in the painful hip after hip arthroplasty.

Diagnosing the cause of hip pain in patients with hip arthroplasty can be challenging because of the numerous possible causes of pain and artifacts caused by the prosthetic components on computed tomography and magnetic resonance imaging. Sonography plays an important role in the diagnosis and management of these patients because the soft tissues surrounding the prosthetic joint are not obscured by artifacts and because sonography enables hands-on examination of the painful site, dynamic evaluation of moving structures, and comparison with the opposite side. Another advantage of sonography is the ability to perform sonographically guided diagnostic and therapeutic procedures. In this pictorial essay, we highlight commonly encountered sonographic findings in patients with hip pain after hip arthroplasty.

Coloarticular fistula: A rare complication of revision total hip arthroplasty.

Fistula formation between bowel and total hip arthroplasty or revision arthroplasty hardware is rare. We present a case of a 78-year-old woman with protrusio of left hip arthroplasty and acetabular reconstruction hardware that caused direct perforation of the sigmoid colon and fistula formation between the sigmoid colon and the left hip joint. The patient underwent several joint debridements, sigmoid colectomy, and removal of all orthopedic hardware; she ultimately died after two prolonged hospitalizations.