Radiographically occult fracture of the tibial epiphysis: sonographic findings with CT correlation.

We report the case of a radiographically occult tibial fracture diagnosed sonographically and confirmed with CT. Ultrasound signs of cortical discontinuity and a three-layered fluid accumulation in the deep infrapatellar bursa were demonstrated.

Sacral insufficiency fractures.

PURPOSE: To highlight difficulties in the diagnostic process and the validity of imaging techniques for sacral insufficiency fractures. METHODS: Records of 25 women aged 68 to 95 years with sacral insufficiency fractures were reviewed. Baseline blood biochemistry and haematology test results were obtained. Pelvic anterior/posterior radiography was undertaken for all patients; additional computed tomography, technetium bone scanning, and magnetic resonance imaging were used in some. Treatments were based on the severity of the injury and the patient's mobility and cooperativeness. RESULTS: Among the 25 women, 11 had bilateral and 14 had unilateral vertical sacral fractures. Associated fractures included horizontal sacral fracture, fractures of the os pubis and ilium. Symptoms included lower back or buttock pain, abdominal pain, and those emulating radiculopathy and myelopathy, including leg weakness, sciatica, and urinary retention. The mean delay in diagnosis was 9 (range, 1-28) days. The mean recovery time between bilateral and unilateral fractures was significantly different (22 [range, 12-33] vs 14 [range, 8-36] weeks, p=0.01). No patient with bilateral fractures regained her pre-injury mobility, compared to 43% among those with unilateral fractures (p=0.02, Fisher's exact test). Computed tomography was the most reliable imaging technique; technetium bone scanning was highly sensitive but non-specific; magnetic resonance images of the fractures may mimic metastatic disease. CONCLUSION: With the increase in the elderly population, sacral insufficiency fractures may become epidemic in future. Primary and secondary osteoporoses are common causes. Once a diagnosis is established, in most cases treatment is simple but recovery may be protracted and full mobility curtailed.

Multislice CT in imaging of trauma of the spine, pelvis and complex foot injuries.

Multislice CT (MSCT) has greatly enhanced the performance of CT scanners and has vastly improved imaging of musculoskeletal trauma. Fast, high resolution scanning is now possible. In our institution, MSCT is an essential part of the imaging of the traumatized patient. The advantages of volume imaging, such as multiplanar reconstructions (MPRs) with near isotropic viewing, three-dimensional imaging and thick slice (wedge) MPRs (mimicking conventional radiographs), enable more accurate assessment of complex anatomical areas such as the spine, pelvis and foot. We discuss the general principles of scanning for musculoskeletal trauma and describe our experience of MSCT of the traumatized spine, pelvis and foot.

Clinical and radiological effects of anakinra in patients with rheumatoid arthritis.

Interleukin-1 (IL-1) is a proinflammatory cytokine that plays a pivotal role in the pathophysiology of rheumatoid arthritis (RA). Inhibiting the activities of IL-1 at the receptor level with the recombinant human IL-1 receptor antagonist anakinra (Kineret; Amgen Inc., Thousand Oaks, CA) is a new therapeutic option for the management of patients with RA. Randomized, placebo-controlled trials have demonstrated that anakinra, alone and in combination with methotrexate, improves the signs and symptoms of RA. Anakinra also produces improvements in patient functionality and health-related quality of life, as measured by the Health Assessment Questionnaire and the Nottingham Health Profile, and reduces the number of productivity days missed due to illness. Furthermore, an initial study indicates that anakinra retards the progression of radiographic joint damage. Such clinical findings suggest that anakinra is an important addition to the rheumatology treatment armamentarium.

Treatment of rheumatoid arthritis patients with interleukin-1 receptor antagonist: radiologic assessment.

OBJECTIVES: The radiologic findings of a placebo-controlled, dose-ranging, multicenter, multinational trial have been reported previously. Radiographs were evaluated using the Larsen scoring method and Erosion Joint Count. After completion of the study, a subset of the films was read again using a modified Sharp score. This article will focus on the methodologies, scoring indices, and outcomes of the Larsen and Erosion Joint Count evaluations. Modified Sharp scores are presented in a separate article. METHODS: A 6-month, phase II, randomized, double-blind, placebo-controlled trial was conducted involving 472 patients with active rheumatoid arthritis. Patients from 41 centers in 11 countries were randomly selected to receive 30 mg/d, 75 mg/d, or 150 mg/d of recombinant human interleukin-1 receptor antagonist (IL-1ra) subcutaneously daily or placebo. Radiographic criteria were circulated to all centers, and the same 2 radiologists used the Larsen score and the Erosion Joint Count to score what was essentially a homogeneous film collection. At the completion of the study, a subset of radiographs also was read using the Genant-modified Sharp score. Patients in any of the treatment arms had the option of continuing in an extension trial for an additional 6 months, and those in the placebo arm had the option of being randomly placed into one of the treatment arms. RESULTS: The Larsen and Erosion Joint Count data from these patients confirm that at 24 weeks, patients receiving placebo worsened by an average of 6.49 Larsen units, whereas those receiving 30, 75, or 150 mg/d of IL-1ra worsened by 3.53, 4.19, and 3.90 Larsen units, respectively. Overall, patients receiving therapy worsened by an average of 3.86 units, achieving statistical significance versus placebo (P = .034). These data are not significantly different from those of the main trial. Mean values were ANOVA-adjusted for country and treatment-group interactions. Similarly, the Erosion Joint Count in placebo patients worsened by an average of 2.64, whereas those receiving 30, 75, or 150 mg/d of IL-1ra worsened by 1.46, 1.05, and 1.70, respectively. The overall therapy and 75 mg/d arm achieved significance versus placebo (P = .002 and P < or = .001, respectively). Preliminary data from the extension study indicate continuing benefit. CONCLUSIONS: Treatment with IL-1ra reduced the rate of joint deterioration and development of new bone erosions.

A multicenter, double-blind, dose-ranging, randomized, placebo-controlled study of recombinant human interleukin-1 receptor antagonist in patients with rheumatoid arthritis: radiologic progression and correlation of Genant and Larsen scores.

OBJECTIVE: To evaluate radiographic progression and the relationship of radiologic scores obtained by the Genant and Larsen methods in a clinical trial of recombinant human interleukin-1 receptor antagonist (IL-1Ra). METHODS: Patients with rheumatoid arthritis (RA) were randomized into 4 groups: placebo (n = 121) or IL-1Ra at a daily dosage of 30 mg (n = 119), 75 mg (n = 116), or 150 mg (n = 116). Hand radiographs obtained at baseline, 24 weeks, and 48 weeks were scored using both methods. RESULTS: At 24 weeks, by the Genant method, there was significant reduction in the score for progression of joint space narrowing (JSN) and the total score (a combination of erosion and JSN) in all treatment groups. Least-squares mean changes in the Genant erosion score from baseline to 24 weeks were significantly reduced after treatment with IL-1Ra at 30 mg/day and for all IL-1Ra treatment groups combined. The changes corresponded to a reduction of 38% in erosion, 58% in JSN, and 47% in total score. Patients treated with IL-1Ra at 75 mg/day had a significant reduction in the Larsen erosive joint count (LEJC), and all IL-1RA-treated groups combined showed a 45% reduction. Correlations (r) between the Genant total and Larsen scores were 0.84 at baseline, 0.83 at week 24, and 0.83 at week 48 (P < 0.0001); correlations between the Genant erosion score and the LEJC were 0.83 (P < 0.0001) at all visits; correlations between the Genant total and the Larsen scores were 0.32 and 0.49 (P < 0.0001) for progression from baseline to week 24 and from baseline to week 48, respectively; correlations between the Genant erosion score and the LEJC were 0.36 and 0.41 (P < 0.0001) for progression to weeks 24 and 48, respectively. CONCLUSION: IL-1Ra reduced radiologic progression of RA. Scores by the 2 methods correlated strongly for each individual time point, but much less strongly for assessments of disease progression.

Ultrasound imaging of forearm fractures in children: a viable alternative?

OBJECTIVE: A pilot study to investigate whether ultrasonography can be reliably used to demonstrate uncomplicated greenstick and torus fractures in children. METHOD: Children between the ages of 2 and 14 years with a high clinical suspicion of a non-articular, undisplaced forearm fracture were included. Ultrasound imaging of the injury was performed by a consultant radiologist who gave an immediate report. Standard radiographs of the forearm were then obtained and the patient treated in the normal way. The radiograph was formally reported on at a later date. RESULTS: 26 patients were included. There was an absolute correlation between the ultrasound and radiographic findings. The procedure was well tolerated. CONCLUSION: Ultrasound seems effective for detecting uncomplicated forearm fractures in children. The procedure is easy to perform and the images easy to interpret. A larger study will now be undertaken to confirm these initial findings.

Treatment of rheumatoid arthritis with recombinant human interleukin-1 receptor antagonist.

OBJECTIVE: To evaluate the efficacy and safety of interleukin-1 receptor antagonist (IL-1Ra) in patients with rheumatoid arthritis (RA). METHODS: Patients with active and severe RA (disease duration <8 years) were recruited into a 24-week, double-blind, randomized, placebo-controlled, multicenter study. Doses of nonsteroidal antiinflammatory drugs and/or oral corticosteroids (< or =10 mg prednisolone daily) remained constant throughout the study. Any disease-modifying antirheumatic drugs that were being administered were discontinued at least 6 weeks prior to enrollment. Patients were randomized to 1 of 4 treatment groups: placebo or a single, self-administered subcutaneous injection of IL-1Ra at a daily dose of 30 mg, 75 mg, or 150 mg. RESULTS: A total of 472 patients were recruited. At enrollment, the mean age, sex ratio, disease duration, and percentage of patients with rheumatoid factor and erosions were similar in the 4 treatment groups. The clinical parameters of disease activity were similar in each treatment group and were consistent with active and severe RA. At 24 weeks, of the patients who received 150 mg/day IL-1Ra, 43% met the American College of Rheumatology criteria for response (the primary efficacy measure), 44% met the Paulus criteria, and statistically significant improvements were seen in the number of swollen joints, number of tender joints, investigator's assessment of disease activity, patient's assessment of disease activity, pain score on a visual analog scale, duration of morning stiffness, Health Assessment Questionnaire score, C-reactive protein level, and erythrocyte sedimentation rate. In addition, the rate of radiologic progression in the patients receiving IL-1Ra was significantly less than in the placebo group at 24 weeks, as evidenced by the Larsen score and the erosive joint count. IL-1Ra was well tolerated and no serious adverse events were observed. An injection-site reaction was the most frequently observed adverse event, and this resulted in a 5% rate of withdrawal from the study among those receiving IL-1Ra at 150 mg/day. CONCLUSION: This study confirmed both the efficacy and the safety of IL-1Ra in a large cohort of patients with active and severe RA. IL-1Ra is the first biologic agent to demonstrate a beneficial effect on the rate of joint erosion.

Interactive image-guided surgery of the spine--use of the ISG/Elekta Viewing Wand to aid intraoperative localization of a sacral osteoblastoma.

The intraoperative localization of small osteoid osteomas and osteoblastomas of the spine is often difficult. The authors report a patient with a small sacral osteoblastoma in whom the experimental use of an Interactive Image-Guidance Stereotactic system, to aid localization, is described. The Elekta Viewing Wand is a spatial localization device primarily designed for intracranial procedures. We evaluated its potential role in the localization and minimally invasive excision of a sacral osteoblastoma in this patient. A basic assessment of the limitations encountered in extracranial use of this system is presented and possible solutions to minimize these problems are discussed.

Routine post-traumatic radiographic screening of midfacial injuries: is one view sufficient?

Midfacial injuries are a common reason for attendance at Accident and Emergency (A&E) departments. A&E staff find these injuries difficult to assess due to limited undergraduate training in maxillofacial examination and early tissue oedema which may mask asymmetry. Patients are therefore referred for 'facial views' radiographs and commonly three views (OM15, OM30, lateral face) are taken for screening. We reviewed prospectively 137 consecutive patients over a 5-month period to determine whether one view (OM15) was sufficient to make a diagnosis in addition to clinical examination. Eighty-three per cent of patients had an accurate diagnosis from just the one view, representing a potential saving of 55 per cent of films taken. There were no fractures missed. The sensitivity was 87.5 per cent and the specificity was 83 per cent. We would suggest the introduction of a single-view facial radiograph as a safe method of screening for midfacial fracture in A&E patients where the clinical diagnosis is uncertain and provided there is no cervical injury. This would reduce costs by reducing films taken by over 50 per cent and patients' exposure to radiation.

Cervical spine imaging in trauma patients: a simple scheme of rationalising arm traction using zonal divisions of the vertebral bodies.

OBJECTIVE: To evaluate the effectiveness of arm traction for cervical spine imaging in trauma patients and devise a scheme to predict the probability of visualising the C7/T1 level in trauma patients. METHODS: 98 trauma patients were studied. Each vertebral body was divided into three equal horizontal zones, the disc space between vertebral bodies being equivalent to one zone. The fifth cervical vertebra was used as the starting level (zone 1). Zones obtained pre and post arm traction on the lateral cervical spine radiographs were recorded. Results were analysed to show the probability of imaging the lower cervical spine, including the cervico-thoracic junction. RESULTS: If the initial film showed less than zone 10 (mid-C7 vertebra), the probability of showing zone 13 (upper body of T1) with arm traction was only 7.7%, that is, one success in every 13 pulls; or conversely, 12 failures in every 13 pulls. CONCLUSIONS: Unless an initial cervical spine radiograph includes the upper one third of the body of the C7 vertebra, the probability of attaining the C7/T1 level with arm traction is < 15%. It is suggested that all initial radiographs of the lateral cervical spine in major trauma patients be done with arm traction, and where the upper one third of the body of C7 vertebra is not seen, then computerised tomography, swimmer's, or oblique views be considered.

Magnetic resonance imaging of acute tendon injury in the finger.

Accurate assessment of flexor tendon function in a digit with an acute, non-penetrating injury is difficult. MR imaging can negate the need for surgical exploration and the associated morbidity.

Extensive infiltration of bone with marrow necrosis in a case of hairy cell leukaemia.

This 32-year-old patient with hairy cell leukaemia demonstrated extensive bony involvement in a pattern not previously described. Although the disease continued to progress during interferon treatment, a change to a regime of deoxycoformycin resulted in an excellent response.

Computer-aided diagnosis: detection and characterization of hyperparathyroidism in digital hand radiographs.

An automated method is developed for the detection and staging of skeletal changes due to hyperparathyroidism on digitized hand radiographs. Subperiosteal bony resorption, particularly along the radial margins of the middle and proximal phalanges, is among the earliest manifestations of secondary hyperparathyroidism. In order to quantify the severity of bone resorption in these regions, the computer method analyzes the roughness of the phalangeal margins, as projected on the radiograph. The regions of interest, which contain the phalanges, are obtained from the digitized hand radiographs by an image preprocessor. The radial margin of each phalanx is detected by a model-guided boundary-tracking scheme. The roughness of these boundaries is then quantified by the mean-square variation and the first moment of the power spectrum. A receiver operating characteristic (ROC) study comparing the computer detection of hyperparathyroidism with the diagnosis by three experienced skeletal radiologists was performed by evaluating 84 hand images from 22 patients. Our present computer method can achieve a true-positive rate of 94% and a true-negative rate of 92%. Such a computer-aided diagnosis system may assist radiologists in their assessment of primary and secondary hyperparathyroidism, since it is both accurate and not subject to either intra- or interobserver variations.

The deep lateral femoral notch: an indirect sign of a torn anterior cruciate ligament.

Magnetic resonance (MR) imaging has shown that tears of the anterior cruciate ligament (ACL) are frequently accompanied by meniscal and osseous injuries. Abnormalities of the cartilage overlying the lateral femoral condylopatellar sulcus (notch) also have been noted during arthrotomy of ACL-deficient knees. In this study, the appearance of this sulcus on MR images and the depth of the sulcus on conventional radiographs are compared in patients with normal and torn ACLs to determine whether a deep sulcus is a useful indirect sign of a torn ACL. In 62 patients with clinically and/or arthroscopically confirmed normal ACLs, the mean depth of the lateral femoral sulcus was 0.45 mm (range, 0.0-1.2 mm) compared with 0.89 mm (range, 0.0-5.0 mm) in 41 patients with clinically and/or arthroscopically confirmed ACL tears (significant at the 5% level). No patient with a normal ACL had a sulcus greater than 1.2 mm in depth. A sulcus deeper than 1.5 mm is equivalent to 3 standard deviations above the mean and was a reliable indirect sign of a torn ACL.

Some commonly unrecognized manifestations of metabolic arthropathies.

The metabolic arthropathies are characterized by the deposition of abnormal substances in or around joints. Certain features of some of these arthropathies and their significance have only recently been recognized and others have been insufficiently emphasized. An important group of conditions are the arthropathies related to renal failure and its treatment, namely, aluminum toxicity, periarticular calcification and crystal deposition, hyperparathyroidism, and dialysis-related amyloidosis. Crystal deposition diseases, specifically, gouty arthritis, calcium pyrophosphate deposition, and calcium hydroxyapatite deposition, are also reviewed.

Dialysis-related amyloid arthropathy: MR findings in four patients.

Dialysis-related amyloidosis is a recently recognized complication of long-term hemodialysis. It is caused by the deposition of a unique form of amyloid derived from circulating beta 2-microglobulin. This study describes the MR imaging characteristics in five articular sites of four symptomatic patients with biopsy-proved (three patients) or clinically and radiographically suspected (one patient) dialysis-related amyloidosis. Three wrists, one knee, and one cervical spine were examined. The extent of osseous and soft-tissue involvement at each joint site was well shown by MR imaging. Lesions that were apparently intraosseous on conventional radiographs were shown to be caused by well-defined erosions that extended to the articular surface. The MR signal characteristics of the amyloid deposition were intermediate between those of fibrocartilage and muscle on all sequences, distinguishing the deposition from cellular lesions or those containing large amounts of water, such as inflammatory masses, acute or chronic synovitis, and brown tumors of hyperparathyroidism. The intraarticular masses were associated with a moderate joint effusion in the large joint imaged, and small effusions were present in the wrist. Use of a fat-suppression sequence enhanced visualization of amyloid deposits within the wrist of one patient but provided no additional information in the knee of a second patient. Our experience suggests that MR imaging is well suited to showing the extent and distribution of articular disease in dialysis-related amyloidosis.

Comparison of transrectal ultrasound and magnetic resonance imaging in the staging of prostate cancer.

A group of 32 patients with a histological diagnosis of prostate cancer underwent transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) to stage the disease. TRUS was more sensitive in the detection of tumour and in the detection of direct extracapsular spread. MRI was more sensitive in the detection of tumour involvement of the seminal vesicles and bladder base. MRI allowed the detection of lymphadenopathy and bone metastases in the lumbosacral spine and pelvis. During MRI the short tau inversion recovery (STIR) sequence was found to be particularly useful for the detection of tumour spread. TRUS and MRI are complementary investigations and for the accurate staging of prostatic malignancy both investigations should be used.