Brachialis tendinopathy: a rare cause of antecubital pain and ultrasound-guided injection technique.

Antecubital pain can be caused by a myriad of pathologies. Abnormalities of the brachialis, in particular, tendinopathy at its insertion, are extremely rare, with no case report in the literature. We report the first case of tendinopathy of the brachialis tendon at its insertion in a 42-year-old male who presented with a year-long history of antecubital pain. The anatomy of the brachialis and the technique for ultrasound-guided steroid injection of the brachialis will also be described.

Is T9-11 the true thoracolumbar transition zone?

OBJECTIVE: Degenerative thoracic stenosis has been shown to most frequently involve the lower thoracic segments (T9-T12) where there is greater mobility and vulnerability due to flexion, extension and rotation of the spine. The thoracolumbar junction is considered anatomically to be T12-L1; the anatomical transition between the relatively immobile thoracic spine and relatively mobile lumbar spine. From anecdotal experience at our institution, we hypothesise that the true thoracolumbar junction is higher, at T10-11; the point of transition from floating to false ribs resulting in increased mobility at T10-11. METHODS AND MATERIALS: A retrospective review was performed of MRI lumbar and whole spine performed on patients aged 10-40 years in our institution over a 5-year period. Patients with previous surgery, chronic spinal disorders and congenital abnormalities were excluded from the study. Intervertebral discs from T8-9 to L1-2 were assessed for evidence of degeneration using the Pfirrmann grading system. Data obtained from a study using computer-based models to assess mean resultant loads in flexion, sitting and standing from T8-9 to L1-2 on patients aged 18-35 years was also analysed. The mean load gradients between two consecutive discs from T8 to L2 were analysed. Statistical analysis was performed with SPSS (p < 0.05 was considered statistically significant). RESULTS: Three-hundred and twenty-two MRI studies were reviewed. Mean Pfirrmann grade was highest at T8-9 and T9-10 (1.35 ±â€¯0.99 and 1.32 ±â€¯0.93 respectively).Pfirrmann grade differed significantly at each level (χ2 = 45.137 p = 0.001). Difference in mean load gradient from T9 to T11 was significantly higher than mean load gradient across T11 to L1 in both sitting and standing (0.095 ±â€¯0.062 vs 0.050 ±â€¯0.044 kN; p = 0.007, and 0.101 ±â€¯0.061 kN vs 0.040 ±â€¯0.054 kN; p = 0.007). CONCLUSION: The changes in segmental loads and more severe disc degeneration at T9-11 compared to T11-L1 support our hypothesis that the true thoracolumbar transition is higher than expected, at T10-11; where the rib cage transitions from floating to false ribs.

Osteochondroma-induced pseudoaneurysms of the extremities mimicking sarcoma: a report of seven contemporary and one historical case.

AIM: To provide a diagnostic approach to distinguish osteochondroma-induced pseudoaneurysm from sarcoma on imaging and prevent biopsy which may be fatal. MATERIALS AND METHODS: A retrospective study of the orthopaedic oncology database was performed to identify all patients referred to specialist orthopaedic oncology service with a final diagnosis of osteochondroma-induced pseudoaneurysm. The demographics of the cohort, the anatomical location of the osteochondromas and pseudoaneurysms, and the imaging appearances were assessed. RESULTS: Seven contemporary and one historical case of osteochondroma-induced-pseudoaneurysm were identified. There were five patients with solitary osteochondroma and three cases of hereditary multiple exostosis. Five cases underwent magnetic resonance imaging (MRI) of which pulsation artefact was present in 40%. On MRI, all the present cases demonstrated a small central pseudoaneurysm surrounded by multiple eccentric layers of thrombus and haemorrhage, which was termed the "eccentric-whorl sign". CONCLUSION: Osteochondroma-induced pseudoaneurysms are often misdiagnosed as malignant transformation of an osteochondroma or a soft-tissue sarcoma and referred for urgent biopsy. This study presents the largest case series, which includes the first documented case diagnosed in 1934. Differentiating and characterising pseudoaneurysms from sarcomas is imperative in order to prevent a biopsy, which could be fatal.

The diagnostic significance of pulmonary nodules on CT thorax in chondrosarcoma of bone.

AIM: To provide a diagnostic approach to pulmonary nodules in patients with chondrosarcoma. MATERIALS AND METHODS: A search of the oncology database at a specialist orthopaedic oncology referral centre was performed to identify all patients who were treated surgically for chondrosarcoma between January 2007 and December 2018. Reports from the computed tomography (CT) examinations of the thorax of these patients were reviewed. In patients who had pulmonary nodules/metastases identified on CT, data on the primary chondrosarcoma and pulmonary nodule characteristics were collected. RESULTS: Twenty point two percent of patients had a pulmonary nodule identified on either initial or follow-up staging CT of the thorax, of which 8.1% were pulmonary metastases. Patients with grade 3 and dedifferentiated chondrosarcoma were more likely to have pulmonary metastases than patients with grade 1/2 chondrosarcoma. The time interval to developing metastases was shorter in patients with grade 2/3 and dedifferentiated chondrosarcoma versus patients with grade 1 chondrosarcoma. A low proportion of patients with grade 1 chondrosarcoma developed metastases (12.5%), all of which were identified at the time of a local recurrence. Nodules ≥10mm, nodules with lobulate margins, nodules containing irregular or subtle calcification, and nodules seen bilaterally or both centrally and peripherally were more likely to represent pulmonary metastases than benign nodules. CONCLUSION: The diagnostic significance of pulmonary nodules (i.e., whether they represent pulmonary metastases or not) can be predicted by taking into account a number of factors, in particular, the histological grade of the patient's chondrosarcoma, the size and margins of the nodules, and the presence of subtle/irregular calcification.

The ring-shaped meniscus: a case series demonstrating the variation of imaging appearances on MRI.

The ring-shaped meniscus (RSM) is a rare meniscal variant in which there is an intermeniscal bridge between the anterior and posterior horns of the meniscus, thus forming a complete ring. The lateral meniscus is more commonly involved than the medial meniscus. Distinguishing an RSM from a bucket handle tear (BHT) with a displaced fragment in the intercondylar notch is challenging and there are reports of negative arthroscopies for suspected BHTs. There are many reports of symptomatic and asymptomatic lateral RSMs diagnosed on MRI in the literature. We report a series of RSMs in six patients, which includes MRI descriptions of two cases of medial RSM and a case of bilateral lateral RSM, which were diagnosed on MRI and have never previously been reported. This study will also describe the various imaging features of a RSM that distinguish it from a displaced BHT. We will also discuss associated rare malformations encountered in our study, such as hypoplastic anterior cruciate ligament and the anomalous insertion of the popliteus tendon onto the posterior horn of a lateral RSM.

Intra-neural ganglion cyst of the lateral dorsal cutaneous nerve: an uncommon cause of lateral ankle pain.

INTRODUCTION: An intra-neural ganglion cyst of the lateral dorsal cutaneous branch of the sural nerve is rare, with only a few cases reported in the literature. MATERIALS AND METHODS: We carried out a retrospective investigation of patients with an intraneural ganglion cyst of the lateral dorsal cutaneous nerve. RESULTS: We present a case series of four patients with intra-neural ganglion cysts of the lateral dorsal cutaneous nerve, the distal continuation of the sural nerve at the lateral aspect of the foot. CONCLUSION: Intra-neural ganglion cysts of the lateral dorsal cutaneous nerve are rare. They represent a relatively uncommon source of lateral ankle pain, which can easily be diagnosed with ultrasound (US) and magnetic resonance imaging and managed effectively with US-guided aspiration or surgical excision.

Calcific tendinopathy of the direct head of rectus femoris: a rare cause of groin pain treated with ultrasound guided percutaneous irrigation.

Groin pain can be caused by a myriad of pathologies. Abnormalities of the rectus femoris are a very rare cause of groin pain; calcific tendinopathy of the direct head is particularly so, with only two case reports in the literature. We report the first case of calcific tendinopathy of the direct head of the rectus femoris that was treated effectively with ultrasound-guided percutaneous irrigation of calcific tendinopathy (USPICT). The anatomy of the rectus femoris and the technique for US-PICT of the rectus femoris are also described.

Dual steristrip technique: a novel use of steristrips to reduce operator radiation dose during CT-guided intervention.

OBJECTIVE: We describe a novel and safe needle-holding method that we have termed the 'dual steristrip technique'. This technique can be used to stabilize the bone biopsy needle without the need for the radiologist's hand to be in close proximity to the X-ray beam during CT-guided intervention. MATERIALS AND METHODS: The dual steristrip technique uses steristrips to stabilize the bone biopsy needle and allows for accurate assessment of needle position and trajectory. This involves affixing one end of a steristrip to the skin 2 cm from the needle skin entry point, wrapping the mid-section of the steristrip around the biopsy needle and affixing the other end of the steristrip to the skin at the opposite side of the needle 2 cm from the needle skin entry point. A second steristrip is then applied in a similar fashion at 90° to the first steristrip. RESULTS: In our institution, we have used the dual steristrip technique to stabilize the biopsy needle in certain cases where assessment of needle position/trajectory can be more challenging. This includes cases where there is a paucity of soft tissues overlying the bone or if the bone lesion is located in the superficial cortex. We have found it to be successful in 80% of cases. CONCLUSIONS: The dual steristrip technique is a safe and effective needle stabilization method that should be considered by the interventional radiologist in challenging CT-guided bone biopsy cases.

Mechanisms of acinar cell injury in acute pancreatitis.

Acute pancreatitis has many causes, all leading to a common pathway of changes within the pancreatic acinar cell. Key amongst these changes is premature intracellular activation of digestive enzymes but this is also accompanied by the appearance of cytosolic vacuoles, co-localization of digestive and lysosomal enzymes, activation of NF-kappaB, and release of pro-inflammatory cytokines. The exact mechanism responsible for enzyme activation remains the subject of much research effort and not a little debate, however it is clear that all of these changes are triggered by an abnormal, sustained rise in cytosolic calcium concentration, which is itself dependent both on release of calcium from endoplasmic reticulum stores and uptake from the extracellular milieu. Activated enzymes are directly damaging to the acinar cell themselves, but recruitment of circulating neutrophils leads to further cellular damage. Cytokines and neutrophil activation are also responsible for the systemic inflammatory response typically seen in severe acute pancreatitis.

Hip osteoarthritis: where is the pain?

BACKGROUND: Pain radiating below the knee is typically thought to originate from the lumbosacral spine rather than degenerative hip pathology. We investigated the lower limb distribution of pain using body image maps in 60 patients awaiting primary hip arthroplasty and in 60 patients awaiting spinal decompression for confirmed spinal stenosis. The perception of 33 orthopaedic registrars regarding distribution of hip pain was also assessed. RESULTS: Groin and buttock pain are significantly more common in hip osteoarthritis. The presence of groin pain is 84.3% of those sensitive for hip dysfunction with a specificity of 70.3%. Patients with hip osteoarthritis had pain below the knee in 47% of cases whereas 88.5% of orthopaedic trainees believed hip pain did not radiate below the knee. Radiographic features of osteoarthritis within the hip joint, visual analogue pain score or Oxford Hip Score have no significant association with a patient's distribution of hip pain. CONCLUSIONS: Hip pain referred below the knee is common with a degenerate hip joint and follows the distribution of the saphenous nerve, which branches from the femoral nerve. Radiographic deterioration of a hip joint does not correlate with pain distribution or patient dysfunction as measured by the Oxford Hip Score.

Mandatory reporting of domestic violence injuries to the police: what do emergency department patients think?

CONTEXT: Laws requiring mandatory reporting of domestic violence to police exist in 4 states. Controversy exists about the risks and benefits of such laws. OBJECTIVE: To examine attitudes of female emergency department patients toward mandatory reporting of domestic violence injuries to police and how these attitudes may differ by abuse status. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey conducted in 1996 of 1218 women patients (72.8% response rate) in 12 emergency departments in California (a state with a mandatory reporting law) and Pennsylvania (without such a law). MAIN OUTCOME MEASURES: Opposition to mandatory reporting to police and the characteristics associated with this belief. RESULTS: Twelve percent of respondents (n = 140) reported physical or sexual abuse within the past year by a current or former partner. Of abused women, 55.7% supported mandatory reporting and 44.3% opposed mandatory reporting (7.9% preferred that physicians never report abuse to police and 36.4% preferred physicians report only with patient consent). Among nonabused women, 70.7% (n = 728) supported mandatory reporting and 29.3% opposed mandatory reporting. Patients currently seeing/living with partners (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.0), non-English speakers (OR, 2.1; 95% CI, 1.4-3.0), and those who had experienced physical or sexual abuse within the last year (OR, 2.2; 95% CI, 1.6-2.9) had higher odds of opposing mandatory reporting of domestic violence injuries. There were no differences in attitudes by location (California vs Pennsylvania). CONCLUSIONS: The efficacy of mandatory reporting of domestic violence to police should be further assessed, and policymakers should consider options that include consent of patients before wider implementation.

An evaluation of a system-change training model to improve emergency department response to battered women.

OBJECTIVES: To evaluate a system-change model of training from the Family Violence Prevention Fund and the Pennsylvania Coalition Against Domestic Violence for improving the effectiveness of emergency department (ED) response to intimate partner violence (IPV). METHODS: An experimental design with outcomes measured at baseline, 9-12, and 18-24 months post-intervention. Twelve hospitals in Pennsylvania and California with 20,000-40,000 annual ED visits were randomly selected and randomly assigned to experimental and control conditions. Emergency department teams (physician, nurse, social worker) from each experimental hospital and a local domestic violence advocate participated in a two-day didactic information and team planning intervention. RESULTS: The experimental hospitals were significantly higher than the control hospitals on a staff knowledge and attitude measure (F = 5.57, p = 0.019), on all components of the "culture of the ED" system-change indicator (F = 5.72, p = 0.04), and in patient satisfaction (F = 15.43, p < 0.001) after the intervention. There was no significant difference in the identification rates of battered women (F = 0.411, p = 0.52) (although the linear comparison was in the expected direction) in the medical records of the experimental and control hospitals. CONCLUSIONS: A system-change model of IPV ED training was effective in improving staff attitudes and knowledge about battered women and in protocols and staff training, as well as patient information and satisfaction. However, change in actual clinical practice was more difficult to achieve and may be influenced by institutional policy.

The power of survivor advocacy: making car trunks escapable.

Survivor advocates are powerful workers for injury prevention. Some of the major prevention successes have been due in large part to their efforts. This case history examines the four year campaign to prevent entrapment in car trunks (or boot) through the routine installation of interior trunk releases. It traces how a life altering event began a cluster of activities leading to product redesign and regulation to prevent injury. The following elements were key: data and the lack thereof, identification of possible solutions, newsworthy tragedies and media advocacy, politics and sympathetic lawmakers, an agency with regulatory authority, manufacturers, and trade associations. Survivors can assist the injury field because the personal and the professional complement each other in advocacy. Public health professionals can assist survivor advocates by sharing research, data and organizational skills, and by helping to secure grants.

Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians.

CONTEXT: Although practice guidelines encouraging the screening of patients for intimate partner abuse have been available for several years, it is unclear how well and in which circumstances physicians adhere to them. OBJECTIVE: To describe the practices and perceptions of primary care physicians regarding intimate partner abuse screening and interventions. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey of a stratified probability sample of 900 physicians practicing family medicine, general internal medicine, and obstetrics/gynecology in California. After meeting exclusion criteria, 582 were eligible for participation in the study. MAIN OUTCOME MEASURE: Reported abuse screening practices in a variety of clinic settings, based on a 24-item questionnaire, with responses compared by physician sex, practice setting, and intimate partner abuse training. RESULTS: Surveys were completed by 400 (69%) of the 582 eligible physicians, including 149 family physicians, 115 internists, and 136 obstetrician/gynecologists. Data were weighted to estimate the practices of primary care physicians in California. An estimated majority (79%; 95% confidence interval [CI], 75%-83%) of these primary care physicians routinely screen injured patients for intimate partner abuse. However, estimated routine screening was less common for new patient visits (10%; 95% CI, 7%-13%), periodic checkups (9%; 95% CI, 6%-12%), and prenatal care (11%; 95% CI, 7%-15%). Neither physician sex nor recent intimate partner abuse training had significant effects on reported new patient screening practices. Obstetrician/gynecologists (17%) and physicians practicing in public clinic settings (37%) were more likely to screen new patients. Internists (6%) and physicians practicing in health maintenance organizations (1%) were least likely to screen new patients. Commonly reported routine interventions included relaying concern for safety (91%), referral to shelters (79%) and counseling (88%), and documentation in the medical chart (89%). Commonly cited barriers to identification and referral included the patients' fear of retaliation (82%) and police involvement (55%), lack of patient disclosure (78%) and follow-up (52%), and cultural differences (56%). CONCLUSIONS: These findings suggest that primary care physicians are missing opportunities to screen patients for intimate partner abuse in a variety of clinical situations. Further studies are needed to identify effective intervention strategies and improve adherence to intimate partner abuse practice guidelines.

Mandatory reporting of intimate partner violence to police: views of physicians in California.

OBJECTIVES: This study examined physicians' perspectives on mandatory reporting of intimate partner violence to police. METHODS: We surveyed a stratified random sample of California physicians practicing emergency, family, and internal medicine and obstetrics/gynecology. RESULTS: An estimated 59% of California primary care and emergency physicians (n = 508, 71% response rate) reported that they might not comply with the reporting law if a patient objects. Primary care physicians reported lower compliance. Most physicians agreed that the legislation has potential risks, raises ethical concerns, and may provide benefits. CONCLUSIONS: Physicians' stated noncompliance and perceived negative consequences raise the possibility that California's mandatory reporting law is problematic and ineffective.