Early diagnosis of femoral neck stress fractures may decrease incidence of bilateral progression and surgical interventions: A case report and literature review.

INTRODUCTION: Early intervention in femoral neck stress fractures (FNSFs) can be self- limiting, but they have an insidious presentation. High index of suspicion for an occult fracture is necessary to avoid bilateral progression and/or operative interventions. CASE PRESENTATION: A 83-year-old female, non-athlete, presents with multiple comorbidities and progressive bilateral FNSFs. Initially the patient presented with groin pain and radiographs demonstrated a non-displaced compression type fracture of the right femoral neck without any inciting events. Subsequently, during a post-operative visit of her right hip, a work-up for new onset contralateral groin pain revealed a non-displaced tension type fracture on the left femoral neck. Both FNSFs were treated with percutaneous cannulated screw fixation. DISCUSSION: Vitamin D deficiency, poor nutrition, and osteoporosis have been associated with developing stress fractures. This presents an interesting question of whether these frequently referenced risk factors play an interrelated role. Treatment algorithms are controversial, but have been successful in preventing the progression of occult stress fractures. Yet, identification of FNSFs represents a major challenge in diagnosis for clinicians. CONCLUSION: This case report documents an uncommon fracture pattern in the elderly population. With an aging population, it is pertinent to avoid missed opportunities for prompt diagnosis and implementation of noninvasive methods of treatment. Therefore, paying attention to the risk factors with a high index of suspicion would be ideal.

ACR appropriateness criteria on metastatic bone disease.

Appropriate imaging modalities for screening, staging, and surveillance of patients with suspected and documented metastatic disease to bone include (99m)Tc bone scanning, MRI, CT, radiography, and 2-[(18)F]fluoro-2-deoxyglucose-PET. Clinical scenarios reviewed include asymptomatic stage 1 breast carcinoma, symptomatic stage 2 breast carcinoma, abnormal bone scan results with breast carcinoma, pathologic fracture with known metastatic breast carcinoma, asymptomatic well-differentiated and poorly differentiated prostate carcinoma, vertebral fracture with history of malignancy, non-small-cell lung carcinoma staging, symptomatic multiple myeloma, osteosarcoma staging and surveillance, and suspected bone metastasis in a pregnant patient. No single imaging modality is consistently best for the assessment of metastatic bone disease across all tumor types and clinical situations. In some cases, no imaging is indicated. The recommendations contained herein are the result of evidence-based consensus by the ACR Appropriateness Criteria((R)) Expert Panel on Musculoskeletal Radiology.

ACR Appropriateness Criteria on suspected osteomyelitis in patients with diabetes mellitus.

Imaging of the diabetic foot is among the most challenging areas of radiology. The authors present a consensus of the suggested tests in several clinical scenarios, such as early neuropathy, soft-tissue swelling, skin ulcer, and suspected osteomyelitis. In most of these situations, magnetic resonance imaging (MRI) with or without contrast is the examination of choice. Most other imaging tests have complementary roles. For soft-tissue swelling or an ulcer, radiography and MRI with or without contrast are suggested. Bone scintigraphy with white blood cell scanning is used when MRI is contraindicated. In patients with diabetes without ulcers, radiography and MRI with or without contrast are suggested; bone scanning may be used when MRI is contraindicated.