Imaging of the Pelvis and Lower Extremity: Demystifying Uncommon Sources of Pelvic Pain.

Pelvic pain can result from gastrointestinal, gynecologic, urologic, neurologic, and musculoskeletal sources. This article focuses on the musculoskeletal lesions that contribute to acute and chronic pain throughout the musculoskeletal core. Armed with an understanding of musculoskeletal core anatomy and biomechanics, imagers play an integral role in the accurate diagnosis and treatment planning for patients with pain and dysfunction from pelvic sources. MR imaging is the primary imaging modality used, but focused sonographic and radiographic techniques have a role. Ultimately, radiologists can help guide patients to the most appropriate subspecialty clinicians based on the underlying source of symptoms.

National Trends in the Utilization of Skeletal Radiography From 2003 to 2015.

PURPOSE: Examine recent trends in the use of skeletal radiography and assess the roles of various nonradiologic specialties in the interpretations. METHODS: Medicare Part B fee-for-service claims data files from 2003 to 2015 were analyzed for all Current Procedural Terminology, version 4 (CPT-4) procedure codes related to skeletal radiography. The files provide examination volume, and we calculated utilization rates per 1,000 Medicare beneficiaries. Medicare's physician specialty codes were used to determine the specialties of the providers. Total utilization rate trends were analyzed, as well as those for radiologists and nonradiologists. We determined which nonradiologist specialties were the highest users of skeletal radiography. Medicare place-of-service codes were used to identify the locations where the services were provided. RESULTS: The total utilization rate per 1,000 of skeletal radiography within the Medicare population increased 9.5% from 2003 to 2015. The utilization rate for radiologists increased 5.5% from 2003 to 2015 versus 11.1% for nonradiologists as a group. Among nonradiologist specialties in all health care settings over the study period, orthopedic surgeons increased 10.6%, chiropractors and podiatrists together increased 14.4%, nonphysician providers (primarily nurse practitioners and physician assistants) increased 441%, and primary care physicians' rate decreased 33.5%. Although radiologists do almost all skeletal radiography interpretation in hospital settings, nonradiologists do the majority in private offices. There has been strong growth in skeletal radiography in emergency departments, but a substantial drop in inpatient settings. CONCLUSIONS: The utilization of skeletal radiography has increased more rapidly among nonradiologists than among radiologists. This raises concerns about self-referral and quality.

Evaluation of the Anterior Talofibular Ligament via Stress Sonography in Asymptomatic and Symptomatic Populations.

OBJECTIVES: Sonography during externally applied stress has the potential to identify ligamentous instability, but diagnostic parameters for the most commonly sprained ankle ligament, the anterior talofibular ligament (ATFL), have not yet been established. The purpose of this study was to determine normative values of the change in the length of the ATFL in an asymptomatic population during manual stress sonography and to compare these values to those in patients with clinical findings of anterolateral ankle instability. METHODS: Sonography of the ATFL at rest and with maximally applied manual stress was performed bilaterally in 20 asymptomatic volunteers from each of three 10-year age groups from 20 to 50 years. Data were compared to those for 34 patients retrospectively identified who underwent stress sonography of the ATFL for clinical signs and symptoms of chronic anterolateral ankle instability. RESULTS: In the asymptomatic population (10 men and 10 women), for men, the mean change in ATFL length between stress and neutral positions was 0.44 mm (95% confidence interval [CI], 0.32-0.57 mm). For women, it was 0.43 mm (95% CI, 0.31-0.55 mm). The difference in laxity between sexes was not significant (P = .85). In the symptomatic population, the mean ATFL length difference between stress and neutral positions was 1.26 mm (95% CI, 0.97-1.55 mm). A t test comparing the mean change in ATFL length showed a statistically significant increase in laxity in the symptomatic group (P < .0001). CONCLUSIONS: The normal ATFL shows minimal laxity in both men and women on stress sonography, with significantly greater laxity among patients with ankle instability. Given these findings, stress sonography may have an important role in the imaging diagnosis of anterolateral ankle instability.

Chronic lesser tuberosity avulsion in an adolescent with an associated biceps pulley injury.

We report a case of a 15-year-old boy with chronic intermittent left shoulder pain due to an undiagnosed lesser tuberosity avulsion fracture, an associated biceps pulley injury and intra-articular dislocation of the long head of the biceps tendon. Lesser tuberosity avulsion fractures are rare injuries that are difficult to detect on clinical exam and radiographically, which may lead to delayed diagnosis and chronic shoulder instability. Few reports describe dislocations or subluxations of the biceps tendon in association with lesser tuberosity avulsions in children. We utilize this case to emphasize the importance of MR not only in detecting lesser tuberosity avulsions, but also in evaluating biceps pulley injuries, which are a rarely reported, but clinically important, association.

Hypovolemic Shock and Hemoperitoneum from Spontaneous Avulsion of a Large Pedunculated Uterine Leiomyoma.

Hemoperitoneum with hypovolemic shock from avulsion of a pedunculated leiomyoma is a rare but highly fatal condition that can occur spontaneously or as a result of trauma. We report a case of hemoperitoneum and hypovolemic shock secondary to a bleeding leiomyoma detected via computed tomography (CT) scan in a 39 year old premenopausal, gravida 0 female that presented with abdominal pain and became hemodynamically unstable in the emergency department. A preoperative bimanual exam revealed a mass consistent with a 20 week gestational uterus. Following fluid resuscitation, the patient underwent emergent myomectomy and ligation of the right uterine artery and was discharged home in good condition.

Clostridium septicum aortitis and colon carcinoma.

BACKGROUND: Clostridium septicum (C. septicum) aortitis is a rare but highly fatal infection that has a strong association with occult malignancy. Aneurysmal transformation of C. septicum aortitis is common and has been reported to occur in as little as 1 to 3 weeks. We report a case of C. septicum Aortitis with concomitant adenocarcinoma of the ascending colon detected via CT scan. Imaging findings of colonic malignancy with aortitis are highly suggestive of infection with C. septicum. Given the high associated mortality and rapid progression, early recognition on imaging could have life saving implications. Additionally, imaging findings of aortitis in conjunction with C. septicum bacteremia should prompt the careful evaluation for malignancy, most notably colonic or hematologic.