ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update.

Osteoporosis constitutes a significant public health risk. An estimated 10.2 million adults in the United States >50 years of age have osteoporosis, a systemic condition that weakens the bones increasing the susceptibility for fractures. Approximately one-half of women and nearly one-third of men >50 years of age will sustain an osteoporotic fracture. These fractures are associated with a decrease in quality of life, diminished physical function, and reduced independence. Dual-energy X-ray absorptiometry (DXA) is the primary imaging modality used to screen for osteoporosis in women >65 years of age and men >70 years of age. DXA may be used in patients <65 years of age to evaluate bone mass density if there are additional risk factors. In certain situations, vertebral fracture assessment and trabecular bone score may further predict fracture risk, particularly in patients who are not yet osteoporotic but are in the range of osteopenia. Quantitative CT is useful in patients with advanced degenerative changes in the spine. Given the proven efficacy of pharmacologic therapy, the role of imaging to appropriately identify and monitor high-risk individuals is critical in substantially reducing osteoporosis-associated morbidity and mortality, and reducing the considerable cost to the health care system. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Imaging After Shoulder Arthroplasty: 2021 Update.

Shoulder arthroplasty is a common orthopedic procedure with a complication rate reported to be as high as 39.8% and revision rates as high as 11%. Symptoms related to postoperative difficulties include activity-related pain, decreased range of motion, and apprehension. Some patients report immediate and persistent dissatisfaction, although others report a symptom-free postoperative period followed by increasing pain and decreasing shoulder function and mobility. Imaging plays an important role in diagnosing postoperative complications of shoulder arthroplasties. The imaging algorithm should always begin with radiographs. The selection of the next imaging modality depends on several factors, including findings on the initial imaging study, clinical suspicion of an osseous versus soft-tissue injury, and clinical suspicion of infection.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Patient Satisfaction in Outpatient Radiology: Effects of Modality and Patient Demographic Characteristics.

Objective: To characterize predictors of patient satisfaction in outpatient radiology, we examined whether patient satisfaction differs across radiology modalities and demographic groups. Methods: A random sampling of Press-Ganey outpatient services surveys for radiology and non-radiology visits from September 2008 to September 2017 were retrospectively analyzed. Composite scores averaged across all Likert items were analyzed as both a continuous variable and a dichotomous variable of dissatisfaction (defined as ≤3 on the 5-point scale). Results: Among 9983 radiology surveys, mammography had higher composite scores than MRI, CT, radiography, US, and NM/PET (p < 0.001) and lower dissatisfaction (3.9%) than CT (6.7%), MRI (7.3%), and radiography (8.2%). Low-scoring responses were most common in the Facilities domain (7.8%) and least common in Overall Assessment (3.8%). Satisfaction metrics were lowest for ages 20-29 and highest for ages 70-79. Lower dissatisfaction rates were seen among Hispanics (3%) and whites (6%), compared to blacks (10%) and Asians (18%). Conclusion: Significant differences in patient satisfaction were found across imaging modalities and demographic variables. Further investigations to identify contributing factors may help improve patient experiences.

ACR Appropriateness Criteria® Chronic Foot Pain.

Chronic foot pain is a frequent clinical complaint, which can significantly impact the quality of live in some individuals. These guidelines define best practices with regards to requisition of imaging studies based on specific clinical scenarios, which have been grouped into different variants. Each variant is accompanied by a brief description of the usefulness, advantages, and limitations of different imaging modalities. The present narrative is the result of an exhaustive assessment of the available literature and a thorough review process by a panel of experts on Musculoskeletal Imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A User Interface for Optimizing Radiologist Engagement in Image Data Curation for Artificial Intelligence.

PURPOSE: To delineate image data curation needs and describe a locally designed graphical user interface (GUI) to aid radiologists in image annotation for artificial intelligence (AI) applications in medical imaging. MATERIALS AND METHODS: GUI components support image analysis toolboxes, picture archiving and communication system integration, third-party applications, processing of scripting languages, and integration of deep learning libraries. For clinical AI applications, GUI components included two-dimensional segmentation and classification; three-dimensional segmentation and quantification; and three-dimensional segmentation, quantification, and classification. To assess radiologist engagement and performance efficiency associated with GUI-related capabilities, image annotation rate (studies per day) and speed (minutes per case) were evaluated in two clinical scenarios of varying complexity: hip fracture detection and coronary atherosclerotic plaque demarcation and stenosis grading. RESULTS: For hip fracture, 1050 radiographs were annotated over 7 days (150 studies per day; median speed: 10 seconds per study [interquartile range, 3-21 seconds per study]). A total of 294 coronary CT angiographic studies with 1843 arteries and branches were annotated for atherosclerotic plaque over 23 days (15.2 studies [80.1 vessels] per day; median speed: 6.08 minutes per study [interquartile range, 2.8-10.6 minutes per study] and 73 seconds per vessel [interquartile range, 20.9-155 seconds per vessel]). CONCLUSION: GUI-component compatibility with common image analysis tools facilitates radiologist engagement in image data curation, including image annotation, supporting AI application development and evolution for medical imaging. When complemented by other GUI elements, a continuous integrated workflow supporting formation of an agile deep neural network life cycle results.Supplemental material is available for this article.© RSNA, 2019.

ACR Appropriateness Criteria® Shoulder Pain-Atraumatic.

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chronic Wrist Pain.

Radiographs are indicated as the first imaging test in all patients with chronic wrist pain, regardless of the suspected diagnosis. When radiographs are normal or equivocal, advanced imaging with MRI (without or without intravenous contrast or following arthrography), CT (usually without contrast), and ultrasound each has a role in establishing a diagnosis. Furthermore, these examinations may contribute to staging disease, treatment planning, and prognostication, even when radiographs are diagnostic of a specific condition. Which examination or examinations are best depends on the specific location of pain and the clinically suspected conditions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Chronic Hip Pain.

Chronic hip pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic hip pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Calcaneal Avulsion Fractures: An Often Forgotten Diagnosis.

OBJECTIVE: The calcaneus is the primary weight bearing bone in the heel, and its many surface contours render it a relatively difficult bone to visualize in its entirety. The stabilizing ligaments that hold the calcaneus in place occupy very specific locations, and the Achilles tendon enthesis is in a relatively constant location; therefore, avulsion fractures occur in reproducible locations. CONCLUSION: The mechanisms of injuries include overuse and neuropathic conditions, although most cases are related to trauma.

Easily Missed Fractures in the Lower Extremity.

As long as radiography remains cheap and provides value in patient care, it will continue to be widely used as a front-line imaging technique. There are limitations to what a radiograph can depict, however. It is imperative to understand the limitations of radiography to avoid pitfalls owing to the overlap of numerous osseous structures. This article reminds the reader of the association between certain radiographic abnormalities and the anatomic relevance in the patient. Although interpretive errors occur in fast-paced, high-volume emergency settings, meticulous attention to changes in the cortex and medullary bone may help to keep errors to a minimum.

Pitfalls in diagnosis: skeletal holes, clefts, and notches.

Radiographs often depict unusually appearing variations in the skeleton that have the appearance of holes, clefts, and prominent notches. Although certain variants are recognizable, others may not be as familiar. Knowledge of characteristic locations of nutrient foramina is also important. The aim of this pictorial essay are to review the anatomic variants in the trunk of the skeleton that manifest as holes, cleft, or notches in the bone and to specify the differentiating features of these variants from those that constitute true pathologic conditions.

MRI of isolated cuboid stress fractures in adults.

OBJECTIVE: Isolated cuboid stress fractures are rare. The purpose of this study was to evaluate the MRI appearance of this condition. MATERIALS AND METHODS: A retrospective search for patients with the diagnosis of a cuboid stress fracture was performed for a 19-year period. All patients underwent an initial three-view radiographic foot series for pain. MRI was performed because symptoms persisted beyond 4 weeks. RESULTS: Ten patients, nine of whom were women, were diagnosed with isolated cuboid stress fractures. These patients were divided into an athletic group (mean age, 36.3 years) and nonathletic group (mean age, 55.0 years). In the athletic group, there were five runners, one ballet dancer, and one gymnast, and in the nonathletic group, there was one with osteoporosis, one with a plantar fascia rupture, and one who recently underwent a fasciotomy. Eight stress fractures were linear and two were stellate and all were surrounded by marrow edema. Six fractures were located inferolaterally, one superolaterally, one laterally, one medially, and one was subchondral in location. All but one involved the peroneal sulcus and cuboid crest region. Nine of 10 feet showed pathology in the plantar fascia, seven in the peroneal tendons, and four in the posterior tibial tendon. CONCLUSION: An isolated stress fracture of the cuboid is most likely to occur in the lateral aspect of the cuboid. The cause is likely multifactorial and may include compressive and tensile forces, but plantar fascia dysfunction and age-related bone loss, which are more prevalent in women, may be additional contributing factors.

The aging athlete: part 1, "boomeritis" of the lower extremity.

OBJECTIVE: The purpose of this review is to describe the physiologic changes that occur in the musculoskeletal system during aging and the common injuries that occur in the lower extremity as a consequence of these changes. Several clinical presentations are addressed, and their differential diagnoses are discussed with an emphasis on the most likely injury for each presentation. CONCLUSION: A unique quality of the newly aging group of people referred to as baby boomers is their expectation to continue exercising as they grow older, thus the incidence of exercise-induced injuries among older people is increasing. The concepts behind factors that predispose older athletes to certain pathologic conditions that affect the muscles, tendons, and bones of the lower extremity must be understood.

The aging athlete: part 2, "boomeritis" of the upper extremity.

OBJECTIVE: The purpose of this review is to describe the upper extremity injuries that frequently accompany aging, the typical clinical presentations, and the differential diagnoses with an emphasis on the injury most likely encountered with each presentation. CONCLUSION: Expectation of continued participation in exercise and sports activities by the baby boomer population has presented new challenges to the medical field. The concepts behind factors that predispose older athletes to certain pathologic conditions that affect the muscles, tendons, and bones of the upper extremity must be understood.

Lateral plantar pain: diagnostic considerations.

Injuries that target the bones of the midfoot are important causes of pain. The medial aspect of the midfoot has been extensively studied but the lateral plantar region has not received as much attention. The objective of this article is to review the differential diagnosis of lateral plantar pain, emphasizing on the common mechanisms of injury, and to identify characteristic imaging findings for these pathologic conditions.

A template approach for detecting fractures in adults sustaining low-energy ankle trauma.

Low-energy trauma such as sprains account for 75% of injuries to the ankle; therefore, ankle pain is one of the most common problems encountered by emergency physicians. A close inspection of the radiographs is often required for diagnosis and this depends on the knowledge of high-risk areas since proper treatment relies on the accuracy of the initial diagnosis. In this article, we will present a template that has helped to increase the accuracy for detecting subtle avulsion fractures, chip fractures, and osteochondral fractures of the hind foot in adults sustaining low-energy ankle injuries. By utilizing this search strategy and understanding where the potential sites for fractures exist, the detection of these subtle fractures can be maximized.

MR imaging of urgent inflammatory and infectious conditions affecting the soft tissues of the musculoskeletal system.

Soft tissue infections and inflammatory conditions of the musculoskeletal system are a group of disorders commonly seen by emergency room physicians and radiologists. Many of these entities can either be limb- or life-threatening. Magnetic resonance imaging is currently the best imaging modality to evaluate these conditions. In this review, the characteristic imaging findings of cellulitis, abscess formation, necrotizing fasciitis, pyomyositis, diabetic ischemic infarction, acute and exertional compartment syndromes, and rhabdomyolysis will be emphasized as well as imaging factors that can help to differentiate these disorders.

Normal MR imaging anatomy of the wrist and hand.

MR imaging is widely used in the evaluation of internal derangement of joints. In the past, the use of hand and wrist MR imaging lagged behind imaging of larger joints,largely because of technical limitations of spatial resolution and signal-to-noise ratio when imaging the small anatomic structures. However, with recent technical advances in extremity coil design, MR imaging has provided us with new insights into the difficult anatomy of the wrist by allowing improved visualization of the relationship of the muscles, ligaments, tendons, and bone. Although the limits of spatial resolution afforded by specialized surface coils and signal processing methods may not have yet been completely realized at 1.5 Tesla, the potential for significant improvements in hand and wrist imaging is likely to rest with the advent of higher strength magnets.