Isolated acute pisiform dislocation presenting atypically as wrist sprain in the emergency department.

The pisiform is a sesamoid bone with in flexor carpi ulnaris tendon. Isolated dislocation of the pisiform bone is not common. It is usually missed and diagnosed as a soft tissue injury or a sprain of the wrist by the emergency physicians. We present an unusual and unique case of a young man involved in a rugby tackle and who himself presented to the emergency department with a painful wrist. The diagnosis of a dislocated pisiform was initially missed; however it was later successfully treated with an open reduction leading to a satisfactory outcome.Early diagnosis and reduction is imperative to avoid prolonged morbidity and loss of earnings. A high index of suspicion is needed in young patients with wrist trauma displaying ulnar sided wrist pain.

The validity and accuracy of MRI arthrogram in the assessment of painful articular disorders of the hip.

The assessment of a patient with chronic hip pain can be challenging. The differential diagnosis of intra-articular pathology causing hip pain can be diverse. These includes conditions such as osteoarthritis, fracture, and avascular necrosis, synovitis, loose bodies, labral tears, articular pathology and, femoro-acetabular impingement. Magnetic resonance imaging (MRI) arthrography of the hip has been widely used now for diagnosis of articular pathology of the hip. A retrospective analysis of 113 patients who had MRI arthrogram and who underwent hip arthroscopy was included in the study. The MRI arthrogram was performed using gadolinium injection and reported by a single radiologist. The findings were then compared to that found on arthroscopy. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and 95% confidence interval were calculated for each pathology. Labral tear-sensitivity 84% (74.3-90.5), specificity 64% (40.7-82.8), PPV 91% (82.1-95.8), NPV 48% (29.5-67.5), accuracy 80%. Delamination -sensitivity 7% (0.8-22.1), specificity 98% (91.6-99.7), PPV 50% (6.8-93.2), NPV 74% (65.1-82.2) and accuracy 39%. Chondral changes-sensitivity 25% (13.3-38.9), specificity 83% (71.3-91.1), PPV 52% (30.6-73.2), NPV 59% (48.0-69.2) and accuracy 58%. Femoro-acetabular impingement (CAM deformity)-sensitivity 34% (19.6-51.4), specificity 83% (72.2-90.4), PPV 50% (29.9-70.1), NPV 71% (60.6-80.5) and accuracy 66%. Synovitis-sensitivity 11% (2.3-28.2), specificity 99% (93.6-100), PPV 75% (19.4-99.4), NPV 77% (68.1-84.6) and accuracy 77%. Our study conclusions are MRI arthrogram is a useful investigation tool in detecting labral tears, it is also helpful in the diagnosis of femoro-acetabular impingement. However, when it comes to the diagnosis of chondral changes, defects and cartilage delamination, the sensitivity and accuracy are low.

The novel appearance of low rectal anastomosis on contrast enema following laparoscopic anterior resection: discriminating anastomotic leaks from "dog-ears" on water-soluble contrast enema and flexible sigmoidoscopy.

PURPOSE: Interpretation of water-soluble contrast enema following laparoscopic low anterior resection can be very challenging for both radiologists and colorectal surgeons. Discriminating the radiological appearances secondary to anastomotic configuration from those caused by actual anastomotic dehiscence is a common problem and may be made worse with the advent of laparoscopic surgery. The aim of this study is to identify potential novel appearances of the water-soluble contrast enema (WSCE) images of rectal anastomosis following laparoscopic low anterior resection to radiologists and surgeons. METHODS: We enrolled 45 patients who underwent laparoscopic low anterior resection with proximal de-functioning loop ileostomy within a specialized colorectal unit. The water-soluble contrast enema reports were reviewed. Two blinded colorectal radiologists independently reviewed the images of patients suspected of anastomotic leak. All of these patients also underwent a flexible sigmoidoscopy to confirm or exclude anastomotic leak before reversal of loop ileostomy. Inter-observer concordance was calculated. RESULTS: Seven out of eighteen patients (38.9%) were found to have true anastomotic leaks on flexible sigmoidoscopy (15% overall leak rate). In the remaining eleven patients the image appearances were attributed to the appearance of the anastomotic 'dog-ear effect', created by the anastomotic configuration due to multiple firing of the intra-corporeal laparoscopic stapling device. Radiologist inter-observer concordance was 83%. Sensitivity was 100%, specificity 71%, positive-predictive value (38.9%) and negative-predictive value (100%). CONCLUSIONS: The novel appearances of laparoscopic-stapled rectal anastomoses in WSCE can be mistaken for anastomotic leak. To avoid delay in reversal of ileostomy, a flexible sigmoidoscopy can be used to confirm or exclude a leak.

Lumbar facet joint septic arthritis presenting atypically as acute abdomen - A case report and review of the literature.

INTRODUCTION: Septic arthritis of the lumbar facet joints is uncommon. The clinical presentation is unusual and patients usually presents with acute back pain or with signs and symptoms mimicking acute abdomen. PRESENTATION OF CASE: A 52year old man was admitted to the surgical ward with acute onset of abdominal pain and a provisional diagnosis of acute pyelonephritis. After the initial inconclusive investigations, magnetic resonance imaging was highly suggestive of lumbar facet joint septic arthritis. He was treated with intravenous antibiotics with complete resolution of infection. DISCUSSION: The diagnosis of septic arthritis of facet joint is becoming more common with MRI scans. The clinical signs and symptoms are usually difficult to differentiate from acute spondylodiscitis. The commonest organism isolated is Staphylococcus aureus. A prompt and early diagnosis and treatment help to eradicate infection and prevent complications. CONCLUSION: The atypical presentation of facet joint septic arthritis is one of the reasons why early diagnosis is elusive. Definitive diagnoses with MRI and bacterial culture as well as prolonged antibiotic therapy are recommended in this condition.

Traumatic avulsion of tibialis anterior following an industrial accident: A case report.

INTRODUCTION: Rupture of the tibialis anterior tendon is uncommon and can occur spontaneously or following trauma. If suspected, it should be diagnosed promptly, enabling early surgical management and good restoration of function. PRESENTATION OF CASE: A 48 year old male sustained a crush injury to his right foot when it became stuck in a vertical industrial fan at work. He attended A & E complaining of swelling of the dorsum of foot. On examination, there was tenderness at the base of the first metatarsal. X-ray revealed an avulsion fracture of the first metatarsal, and MRI showed rupture of tibialis anterior. The patient underwent surgical repair 10 days later, with post-operative management in a non-weight bearing, then weight bearing cast. X-ray at 8 weeks showed that the fracture had healed. The patient had a course of physiotherapy and was followed up at 6 months to assess pain and function. DISCUSSION: Tibialis anterior rupture should be considered if the history is suggestive, and can be diagnosed clinically based on the triad of a 'pseudotumour' of the ruptured tendon, loss of tendon contour, and reduced dorsiflexion of the ankle. In our case, the avulsion fracture prompted further imaging to confirm the diagnosis and plan surgery. There are various operative technique described in the literature. We used a whip stitch with anchors to reattach the tendon to the base of first metatarsal. CONCLUSION: A prompt and early diagnosis of surgical repair of tibialis anterior tendon avulsion is important to ensure that the patients return to work as an industrial worker.

Secondary frozen shoulder following septic arthritis - An unusual complication of magnetic resonance arthrogram.

INTRODUCTION: Magnetic resonance (MR) arthrogram is a commonly used investigation tool to detect various pathologies in the shoulder. The complications following this procedure is minor and rare. Septic arthritis is one of the rare complications which can develop after MR arthrogram. We report a case of secondary frozen shoulder after MR arthrogram induced septic arthritis. PRESENTATION OF CASE: A young, fit and well female patient underwent MR arthrogram to detect any labral tears. Two days following the procedure, she developed signs and symptoms suggestive of septic arthritis of the shoulder. The patient underwent repeated arthroscopic debridement and washout. The organisms isolated was Staphylococcus epidermidis. She was treated with six weeks of intravenous antibiotics. The patient developed stiffness of the shoulder due to secondary frozen shoulder which was treated with arthroscopic capsular release with good functional outcomes at three months. DISCUSSION: MR arthrogram is a rare cause of septic arthritis of the shoulder. The common method introducing the organisms is from the skin flora or contaminated arthrogram trays. The treatment is repeated arthroscopic washouts and six weeks of appropriate intravenous antibiotics. Residual pain, stiffness and chondrolysis are common sequelae of septic arthritis. CONCLUSION: Septic arthritis is a recognised and rare complication of MR arthrogram. Early and prompt diagnosis with arthroscopic washout and debridement combined with intravenous antibiotics helps to eradicate the infection. Secondary frozen shoulder is a late complication of sepsis in the joint.

The value of delayed MRI scans in the assessment of acute wrist injuries.

The aim of this study was to better quantify the role of delayed MRI scans in acute wrist injuries, and to assess the prevalence and distribution of multiple occult injuries of the wrist. A retrospective study was made of all patients who had been referred to the orthopaedic trauma clinic for a possible scaphoid fracture and with normal radiographs over a two year period. There were 110 patients. Patients were initially treated conservatively with a scaphoid cast or a futura splint for two weeks. This was then removed and the wrist examined and further radiographs taken. The patients with normal radiographs who had positive clinical findings for a scaphoid fracture at two weeks or persisting pain at six weeks had an MRI scan. MRI was performed with and without fat saturation sequences. A total of 110 wrists were analysed. Twenty-eight (25.4%) were reported as normal; 24 patients (21.8%) had occult bone fractures. Three (2.7%) had scaphoid fractures diagnosed by MRI scans. There were nine (8.1%) distal radius, two trapezium and five hook of hamate fractures. Bone bruising was seen in 12 (10.9%). Carpal degeneration was seen in ten and a TFC tear was noted in five (4.5%). Other findings were a ganglion in 14 (12.7%) and three (2.7%) had Kienbock's disease. The MRI scan is a useful tool in obtaining a definite diagnosis in acute wrist injuries. Among other findings, an occult scaphoid fracture was diagnosed on MRI in 2.7% of cases in this study. To conclude, in the majority of patients with persisting symptoms after two weeks following a wrist trauma, the cause of symptoms was pathology in other tissues in the wrist including soft tissues, other carpal bones and distal forearm.

An unusual presentation of a giant tumour-like lesion of the thigh.

Soft tissue swellings of the thigh, which become painful and are gradually increasing in size, should always raise the suspicion of a soft tissue tumour. We report a case of a clinically silent chronic granuloma formation, which presented 45 years later as a giant tumour-like lesion. A metallic foreign body implanted following an injury was found as the source of the tissue reaction. This is the longest period of delay to presentation described in the English literature for the clinical manifestation of a granulomatous reaction.