Design and Validation of a Peer-Teacher-Based Musculoskeletal Ultrasound Curriculum.

RATIONALE AND OBJECTIVES: To design and validate a peer-teacher based musculoskeletal ultrasound curriculum for radiology residents. MATERIALS AND METHODS: A musculoskeletal ultrasound curriculum with hands-on scanning workshops was designed for radiology residents. Prior to the workshops, several residents received 3 hours of hands-on training in ultrasound scanning technique which was overseen by an attending musculoskeletal radiologist; these "peer teachers" then led small-group hands-on scanning during the workshops. Participants performed diagnostic ultrasound examinations at the conclusion of the workshops to assess skill acquisition and 2 months following the workshops to quantify skill retention. Participants also completed surveys to determine confidence in performing musculoskeletal ultrasound examinations. Median scores and interquartile range (25-75%) were calculated, and t test was used to compare results. RESULTS: Thirty seven residents from all years of training and six senior resident or fellow peer teachers participated in four workshops. Diagnostic ultrasound images were obtained in 100% at the conclusion of the workshop and in 79% 2 months later. Prior to the workshops, residents reported low level of musculoskeletal ultrasound knowledge (median 2, interquartile ranges 1-2), and low confidence in performing (1, 1-2) and interpreting (1, 1-2) musculoskeletal ultrasound examinations. There was a significant increase in knowledge (3, 3-4) and confidence performing (3, 3-4) and interpreting (3, 3-4) studies following the workshops (p < 0.001 for all comparisons). CONCLUSION: Hands-on musculoskeletal ultrasound workshops, utilizing a peer teacher led small group format is an effective method of teaching scanning skills to residents. There was excellent skill acquisition, good skill retention, and significant increase in confidence performing and interpreting these studies following completion of the curriculum.

Characterization and Surgical Management of Metastatic Disease of the Tibia.

Osseous metastases are common in advanced cancer stages. The tibia is the appendicular skeleton bone affected third most often. However, tibial metastases are not well described. We conducted a retrospective descriptive single-institution study of patients with evidence of tibial metastatic disease in order to better characterize tibial metastases in their anatomical distribution and histology, and to describe their clinical presentation and surgical management. Using proprietary research software, we searched pathology and radiology reports and cross-referenced results with Current Procedural Terminology procedure codes to identify patients with metastatic lesions of the tibia. We then reviewed these patients' medical records and reviewed and verified all available imaging. We reviewed the medical records of 36 patients (20 females, 16 males) with 43 affected tibiae. Mean age was 63.5 years. Of 12 different primary neoplasms, the most common were prostate, breast, and lung cancers. The proximal tibia was the region most commonly affected, followed by the diaphysis. Of 6 impending fractures, 3 were treated with intramedullary nail, 2 with total knee megaprosthesis, and 1 with total knee arthroplasty. Of 2 pathologic fractures, 1 was treated with intramedullary nail and 1 with periarticular locking plate. Almost all identified patients (88.9%) had other metastatic lesions. Almost half (47.2%) of patients presented with symptomatic tibia lesions. Mean time from diagnosis of malignancy to tibial metastasis was 1282 days (range, 0-3708 days). Metastases to the tibia are uncommon but often require surgical intervention. Fixation technique should be selected on a case-by-case basis, and patients should be treated by a multidisciplinary team. Patients with known malignancy and tibial pain should undergo a work-up for tibia lesions.

Survey of current trends in postgraduate musculoskeletal ultrasound education in the United States.

OBJECTIVE: To determine current trends in postgraduate musculoskeletal ultrasound education across various medical specialties in the United States. MATERIALS AND METHODS: A survey regarding musculoskeletal ultrasound education was sent to all program directors for diagnostic radiology and physical medicine rehabilitation residency programs, as well as adult rheumatology and sports medicine fellowship programs in the United States. The survey, sent in July 2015, queried the presence of formal musculoskeletal ultrasound training, the components of such training and case volume for trainees. RESULTS: Response rates were 23, 25, 28 and 33% for physical medicine and rehabilitation, radiology, rheumatology and sports medicine programs, respectively. Among respondents, musculoskeletal ultrasound training was present in 65% of radiology programs, 88% of sports medicine programs, 90% of rheumatology programs, and 100% of physical medicine and rehabilitation programs. Most programs utilized didactic lectures, followed by hands-on scanning. The majority of programs without current training intend to implement such training within 5 years, although radiology programs reported the lowest likelihood of this happening. Most program directors believed that musculoskeletal ultrasound education is important for their trainees, and is of greater importance than it was 10 years ago. Case volume was lowest for radiology trainees and highest for sports medicine trainees. CONCLUSION: Among respondents, the majority of diagnostic radiology programs offer musculoskeletal ultrasound training. However, this experience is even more widespread in other medical specialties, and hands-on training and experience tend to be greater in other specialties than in radiology.

MRI findings in pediatric patients with scurvy.

In modern times scurvy is a rarely encountered disease caused by ascorbic acid (vitamin C) deficiency. However, sporadic cases of scurvy persist, particularly within the pediatric population. Recent individual case reports highlight an increased incidence of scurvy among patients with autism or developmental delay, with isolated case reports detailing the magnetic resonance imaging (MRI) findings of scurvy in these pediatric populations. We present the MRI findings of scurvy in four patients with autism or developmental delay, and review the literature on MRI findings in pediatric patients with scurvy. Despite its rarity, the radiologist must consider scurvy in a pediatric patient with a restricted diet presenting with arthralgia or myalgia.

Imaging appearances of musculoskeletal developmental variants in the pediatric population.

Variations in musculoskeletal development in children are commonly encountered. These variants often have a confusing appearance on imaging and may simulate pathologic conditions. However, in many instances, these normal variants have certain features that allow for confident determination of the benign nature of these entities. An awareness of the characteristic imaging features is therefore important for radiologists. In this review, we focus on 4 specific categories of variants in the development: (1) variations in the normal ossification of skeletal structures, (2) the appearance of tendinous and ligamentous insertions in the developing skeleton, (3) overlapping lines that can be confused with fractures or other pathologic conditions, and (4) variant orientation of normal bones. We review the etiology and imaging appearance of these entities and also describe methods of differentiating these benign entities from pathologic lesions. Although in certain cases, correlation with clinical parameters is needed to confidently diagnose the lesion as benign, in many cases, an appreciation of the characteristic imaging features alone would suffice and prevent a potentially costly workup.

Aggressively recurrent infantile myofibroma of the axilla and shoulder girdle.

Infantile myofibroma is the most common fibrous tumor of infancy, typically affecting neonates and children under 2 years of age. Though the multicentric variant portends a grave prognosis, solitary lesions have an excellent prognosis and frequently undergo spontaneous regression. Surgical excision of solitary lesions is usually curative. In this report, we describe a pediatric patient with an unusually aggressive solitary myofibroma of the axilla who ultimately required a forequarter amputation as a lifesaving measure following multiple tumor recurrences and progressive tumor growth. The clinical course, radiographic findings, histology, and management rationale are presented.

Pain in the butt: spectrum of gluteal region abnormalities in children.

OBJECTIVE: The purpose of this study was to illustrate the spectrum of solitary gluteal lesions in children. The distinctive anatomic and radiologic features are discussed. CONCLUSION: Pathologic entities in the gluteal region reflect the diversity of tissue types present. Ultrasound is valuable for imaging of infants and young children and for evaluating superficial lesions. Cross-sectional imaging is most useful for defining the extent of disease and may show pathognomonic features, enabling a precise diagnosis.

Cryptococcal pyarthrosis and sarcoidosis.

Cryptococcus neoformans is an infrequent cause of septic arthritis. Cryptococcal infections have been linked to sarcoidosis because of both inherent immunologic consequences of the disease and its typical immune modulating treatments. Cryptococcal infections should be suspected in patients with underlying immune deficiencies, and a high degree of vigilance should be exercised to avoid misdiagnosis, dissemination of infection, and meningitis.

Spontaneous hemorrhage simulating rapid growth of a benign subperiosteal plexiform neurofibroma.

Spontaneous subperiosteal hemorrhage is a rare complication of von Recklinghausen's disease. There are few reports describing the MR imaging characteristics of this entity. Our case is unique among these as an underlying plexiform neurofibroma was visualized by MR imaging. We present a 12-year-old child with neurofibromatosis 1 who presented with a rapidly enlarging mass of the fibula. Surgery and pathology revealed subperiosteal hemorrhage into a benign, plexiform neurofibroma. The MR imaging features, pathogenesis and clinical implications of this entity are discussed. Recognition of this disease process and differentiating it from malignant transformation can prevent unnecessary surgery.