Lateral elbow tendinopathy: surgery versus extracorporeal shock wave therapy.

Lateral elbow pain caused by tendinopathy - tendinosis - or tennis elbow is a highly prevalent problem. Unfortunately, no treatment method can guarantee clinical success. Inspired by the lithotripsy technique used for kidney stones, extracorporeal shock wave therapy (ESWT) has been introduced as an alternative to surgical treatment 25 years ago. In a randomized prospective study, we compared 15 patients with lateral elbow tendinopathy who were operated and 14 who underwent ESWT. Almost all patients had good or excellent outcomes according to the criteria by Verhaar. Subjective improvement was 57% for the ESWT group and 76% for the surgery group. No significant differences between both groups were found (p = 0.07). We therefore recommend considering non-invasive techniques such as ESWT treatment prior to surgery in tennis elbow.

Longitudinal cortical split sign as a potential diagnostic feature for cortical osteitis.

Septic cortical osteitis is a rare but distinct type of bone infection that is characterized as a hematogenously seeded infection predominantly or exclusively limited to the cortex. Diagnosis is difficult and often delayed. Combination of clinical and laboratory findings together with the typical radiological findings consisting of vertically orientated cortical osteolysis, the 'cortical split sign' and the predominantly cortical disruption at the periosteal side of the cortex may lead to the correct diagnosis.

Ewing's sarcoma: imaging features.

AIM: To define an imaging prototype of Ewing's sarcoma (ES). MATERIALS AND METHODS: Sixty-four patients with a histopathologically and/or genetically proven diagnosis of ES were analyzed for clinical parameters (age, gender and location), radiographic and CT appearance (distribution, matrix, margins, periosteal reaction, articular extension, cortical reaction and the presence of a pathologic fracture). Size, local extension, signal intensity, degree and pattern of enhancement, and the presence of skip metastases were evaluated on MRI. Distant metastases were recorded on bone scintigraphy and chest CT scan. RESULTS: Patient's age ranged between 7-67 (mean 17.9). Male/female ratio was 2.4/1. Location in the pelvis was most frequent (31%), followed by the femur (20%) and tibia (11%). Most tumors were mixed lytic-sclerotic (75%), and purely lytic in 25%. Plain films and CT scan showed a spiculated periosteal reaction in 50%. A Codman's triangle was seen in 27%. Articular extension was difficult to assess on radiographs. Cortical permeation and destruction is seen in respectively 31 and 42%, whereas cortical thickening is seen in 20%. Pathologic fracture occurred in 7.8%. MRI showed a large mass, with a soft tissue component of more than 50% in 67%. Degree and pattern of enhancement pattern was variable. Signal intensity on T1- and T2-WI was non-specific. Joint involvement was seen in 23%. Isolated involvement of the soft tissue (extraskeletal ES) was seen in 1.5%. Skip metastases at initial presentation were present at initial presentation in 14% and distant metastases in 22%. CONCLUSIONS: ES occurs in young patients. On radiographs/CT, 37.5% are located in the axial skeleton and 62.5% in the peripheral skeleton. ES is mostly mixed sclerotic-lytic. A spiculated periosteal reaction is most frequent. The most characteristic finding on MRI is the presence of a large soft tissue mass.

A special case on the use of ultrasonography for evaluation of the spinal canal and its contents in adults.

In this article we present a 70-year-old man with a history of severe trauma in the upper thoracic spine. This patient presented at our emergency department with a leaking wound in the lower neck after removal of osteosynthetic material. He had undergone a laminectomy of the third thoracic vertebra in the past. As an incidental finding, while examining the region of the lower neck by transcutaneous ultrasonography, we diagnosed a post-traumatic syrinx of the spinal medulla at this level.

Imaging in trauma of the pelvis and hip region.

Trauma of the pelvis and the hip are frequent and the most common lesions are fractures and dislocations. There are other traumatic lesions around the pelvis, including epiphysiolysis of the femoral head and apophysiolysis of the common muscle insertions around the hip. Cartilaginous lesions and some less frequent fractures are also illustrated in this article. We are not claiming to give a complete overview of traumatic injuries to the pelvis and the hip, but want to illustrate some more and some less frequent lesions.

Non perforated septum supra-patellaris mimicking a soft tissue tumour.

Plicae synoviales of the knee are well known to present as anterior knee pain but can also cause blocking, clicking, and swelling of the knee mimicking pathology such as meniscal tears or other internal derangements, and even mono-arthritis. Embryologically, the knee is divided into a medial and lateral compartment and a supra-patellar pouch by thin membranes of synovium. Incomplete involution of these membranes gives rise to a plica. When there is no involution at all, the membrane is called a septum. There are three frequent types of plicae/septa: a suprapatellar, a medial-patellar, and an infra-patellar type. We discuss on a patient with a non perforated septum supra-patellaris which resulted in a swelling above the knee, mistaken for a soft tissue tumour.

The meniscal ossicle revisited.

The meniscal ossicle is an infrequent radiographic finding in humans. It often is mistaken for an intra-articular loose body. MR imaging is the ideal modality to differentiate between these entities. We report the imaging findings of a meniscal ossicle in a patient with emphasis on the MR imaging appearance. A review of the literature on meniscal ossicles is also presented.

Fibrolipomatous hamartoma in the foot: atypical MR imaging findings.

Lipomatosis of a nerve is a well-known but uncommon entity mostly seen in the median nerve. Magnetic resonance imaging (MRI) has been shown to provide pathognomonic features, obviating the need for diagnostic biopsy. We present a case of lipomatosis of a branch of the medial plantar nerve with an atypical appearance on magnetic resonance imaging.

Selective arterial embolization in the treatment of an aneurysmal bone cyst of the pelvis.

This case report deals with an aggressive aneurysmal bone cyst of the pelvis in a 20-year-old man causing considerable destruction of the left ilium and the anterior column of the acetabulum, with extension into the pelvis. The treatment of large pelvic aneurysmal bone cysts is challenging because of local destruction of adjacent structures and because of the risk of severe intraoperative bleeding. Therefore selective preoperative embolization may be a valuable tool in the management of aneurysmal bone cysts.

The axis ring: a forgotten semiologic sign in the detection of low odontoid fractures.

The axis ring is a very important sign in the detection of low odontoid fractures. It can be the only radiological sign of a type III (low) odontoid fracture in a polytraumatised patient. As these are unstable fractures, their detection is important, even before a spiral CT is performed. Tracheal tube placement in patients with type III odontoid fractures should be performed very carefully to prevent displacement of the fracture. This sign, which has been published more than once in the radiological literature, seems to be not so well known by the physicians nor by a lot of radiologists. We can call it a forgotten semiologic sign. It is not even mentioned in the ATLS (Advanced Trauma Life Support) criteria for evaluation of the cervical spine.

Ultrasound in acute trauma of the ankle and hindfoot.

Ultrasound is a rapid, widely available and inexpensive imaging modality for the evaluation of the ankle and hindfoot. Ultrasonography can be performed in acute, semiacute and chronic conditions. Ankle injuries can be evaluated with ultrasound combined with X-rays. In the emergency room, acute trauma of ankle and hindfoot is an important indication for ultrasound.

Unilateral absence of the trapezius and pectoralis major muscle: a variant of Poland syndrome.

We report a female patient with unilateral absence of the trapezius and pectoralis major muscles without other associated limb abnormalities. We believe that this anomaly belongs to the spectrum of anomalies resulting from disruption of the blood supply in the embryonic subclavian and vertebral arteries, as suggested in Poland syndrome.

Calcifying/ossifying synovial sarcoma shows t(X;18) with SSX2 involvement and mitochondrial calcifications.

AIMS: Synovial sarcoma with extensive calcification and ossification is a rare variant, the ultrastructural, cytogenetic and molecular analysis of which has not been reported previously. METHODS AND RESULTS: A large mass in the shoulder of a 20-year-old male patient led to a deformity of the chest wall, thus supporting the hypothesis that this is a slowly growing variant of synovial sarcoma. Nevertheless, the patient developed metastatic lung disease 7 months after resection. On histology, the monophasic spindle cell proliferation was in several areas obscured by the massive calcification and ossification. Immunohistochemistry showed keratin, epithelial membrane antigen, vimentin and CD99 expression. The cytogenetic analysis revealed a single t(X;18)(p11.2; q11.2), typical for synovial sarcoma. Additional fluorescence in-situ hybridization revealed SSX2 involvement. At the ultrastructural level, prominent needle-shaped intramitochondrial crystals were present, both in the cytoplasm and in the extracellular matrix. CONCLUSION: The presence of the t(X;18) with SSX2 involvement definitively characterizes this tumour as a variant of synovial sarcoma. In addition, the needle-like mitochondrial calcifications give a possible clue to the pathogenesis of the extensive metaplastic ossification and calcification.

Recurrent chromosome aberrations in fibrous dysplasia of the bone: a report of the CHAMP study group. CHromosomes And MorPhology.

The nosologic status of fibrous dysplasia (FD), a well-known and relatively common bone lesion, is controversial. Information collected by the CHromosomes And MorPhology (CHAMP) study group on published and unpublished cases of fibrous dysplasia shows the presence of clonal chromosome changes in at least a proportion of these lesions. The chromosome aberrations found in FD lesions have been quite variable and have included both structural and numerical changes. Two of the three cases investigated at the study group had trisomy 2 as the sole acquired anomaly. Combined with previously published data, +2 and rearrangements involving chromosome band 12p13 have each been detected in 3 of 8 cases with abnormal karyotype of 11 in which chromosomal analysis has been performed, suggesting that FD is a neoplastic lesion rather than a "dysplastic" process, as has been generally believed and as implied by its very name.

Imaging in pelvic trauma.

Pelvic injuries are an important issue in trauma patients, largely as a result of the major disruptive forces required to fracture the pelvic ring. Despite the growing influence of more sophisticated techniques such as CT and MR in the evaluation of pelvic trauma, conventional imaging remains important, especially in the initial detection of fractures. Several plain film incidences can be used to detect and evaluate a fracture, so that the exact diagnosis can be made in the emergency room. For operative planning CT and especially 3D reconstruction are very useful. Cystography can be used to detect bladder ruptures. Angiography can detect the bleeding site, and therapeutic embolization can stop bleeding. MR imaging is becoming more important, as it can detect occult fractures, especially in the elderly patient.

Cytogenetic-morphologic correlations in aneurysmal bone cyst, giant cell tumor of bone and combined lesions. A report from the CHAMP study group.

Aneurysmal bone cyst and giant cell tumor of bone are relatively rare bone tumors that sometimes coexist. We examined the karyotypes of 3 aneurysmal bone cysts, 12 giant cell tumors, and 3 combined lesions. All aneurysmal bone cysts showed involvement of chromosome segments 17p11-13 and/or 16q22. In addition, in 1 of the 3 giant cell tumors with secondary aneurysmal bone cyst, both chromosome bands were rearranged as well, albeit not in a balanced translocation. Seven out of 12 giant cell tumors were characterized by telomeric associations. One giant cell tumor showed a dup(16)(q13q22), suggesting the presence of a (minor) secondary aneurysmal bone cyst component, despite the absence of histological proof. Our results, combined with literature data further substantiate that segments 16q22 and 17p11-13 are nonrandomly involved in at least some aneurysmal bone cysts, irrespective of subtype (primary, secondary, intra/extraosseous, solid or classic). These findings strongly suggest that some aneurysmal bone cysts are true neoplasms. In addition, telomeric associations are the most frequent chromosomal aberrations in giant cell tumor of bone, the significance of which remains elusive. In combined giant cell tumor/aneurysmal bone cyst each component seems to retain its own karyotypic abnormality.

Iatrogenic pseudoaneurysm in the upper arm: treatment by transcatheter embolization.

A 32-year-old woman presented with a pulsatile, painful mass in her left upper arm, originating several days after removal of an Ilizarov external fixation. The diagnosis of a pseudoaneurysm was made by medical history and by physical and ultrasonographic examination of the mass. Angiography confirmed the presence of the pseudoaneurysm, originating from a branch of the arteria profunda brachii, and definitive treatment was performed by transcatheter embolization. Clinical follow-up showed absence of pulsation and pain in the upper arm and a gradual volume decrease of the mass lesion.

The role of the reversed oblique radiograph in trauma of the foot and ankle.

The objective of this study was to demonstrate the statistical significance of a reversed oblique radiograph of the foot in patients with ankle or foot trauma. In 100 consecutive patients a reversed oblique radiograph of the foot was taken in addition to the conventional plain films. Ten of 29 fractures were not visualised on the conventional films of foot and ankle and could only be diagnosed on the reversed oblique film. In 7 of these 10 cases an avulsion fracture at the anterolateral aspect of the calcaneus was present. This additional reversed oblique film of the foot seems to be of considerable importance, especially when an anterolateral avulsion fracture of the calcaneus is clinically suspected.

Langerhans cell histiocytosis of the clavicle: a case report.

A case of Langerhans cell histiocytosis in a 47-year-old male presenting as an aggressive appearing lesion of the clavicle is reported. It illustrates the difficulties of the radiological diagnosis of a solitary bone lesion.