Aaron B. Welk

Magnetic resonance imaging investigation of the atlanto‐axial interspace

The objective of this study is to examine the anatomy of the atlanto‐axial interspace using magnetic resonance (MR) imaging. Two hundred and forty MR images of living subjects were examined for the presence of a posterior dural prominence and oblique hypointense fibers between the first and second cervical neural arches. Of the 240 images analyzed, 64% revealed a posterior concavity of the cervical dura mater. Of this, 24% also revealed oblique, linear hypointense fibers that appeared to be in direct contact with the dura mater. Twenty‐three percent of the 240 images revealed oblique, linear hypointense fibers. Of the 23% that exhibited these fibers, 76% had an associated posterior thecal concavity of the cervical dura mater. A posterior dural prominence and oblique hypointense fibers were present in the atlanto‐axial interspace in a significant number of randomly selected magnetic resonance images. These findings may represent normal, nonpathological anatomy found on MR images and may be related to a recently reported anatomical structure. Clin. Anat. 2013.

Reliability of the Goutallier Classification in Quantifying Muscle Fatty Degeneration in the Lumbar Multifidus Using Magnetic Resonance Imaging

OBJECTIVE The purpose of this study was to investigate the reliability of the Goutallier classification system (GCS) for grading muscle fatty degeneration in the lumbar multifidus (LM) using magnetic resonance imaging (MRI) examinations. METHODS Lumbar spine MRI scans were obtained retrospectively from the radiology department imaging system. Two examiners (a chiropractic diagnostic imaging resident and a board certified chiropractic radiologist with 30 years of experience) independently graded each LM at the L4/5 and L5/S1 intervertebral level. ImageJ pixel analysis software (version 1.47; National Institutes of Health, Bethesda, MD) was used independently by 2 observers to quantify the percent fat of the LM and allow correlation between LM percent fat and GCS grade. Twenty-five subject MRIs were randomly selected. Magnetic resonance imaging scans were included if they were obtained using a 1.5 T imaging system and were excluded if there was evidence of spinal infection, tumor, fracture, or postoperative changes. For all tests, P < .05 was defined as significant. RESULTS Intraobserver reliability grading LM fat ranged from a weighted κ (κw) of 0.71 to 0.93. Mean interobserver reliability grading LM fat was κ(w), 0.76 to κ(w), 0.85. There was a significant (P < .001) correlation between LM percent fat and GCS grade. Furthermore, interobserver reliability in determining percent fat was between intraclass correlation coefficient, 0.73 to intraclass correlation coefficient, 0.90. CONCLUSIONS In this study, the GCS was reliable in grading LM fatty degeneration and correlated positively with a quantified percent fat value. In addition, ImageJ software (National Institutes of Health) was reliable between raters when quantifying LM percent fat.

Use of high-resolution ultrasound to measure changes in plantar fascia thickness resulting from tissue creep in runners and walkers.

OBJECTIVE This study sought to use high-resolution ultrasound to measure changes in plantar fascia thickness as a result of tissue creep generated by walking and running. METHODS Independent samples of participants were obtained. Thirty-six walkers and 25 runners walked on a treadmill for 10 minutes or ran for 30 minutes, respectively. Standardized measures of the thickness of the plantar fascia were obtained in both groups using high-resolution ultrasound. RESULTS The mean thickness of the plantar fascia was measured immediately before and after participation. The mean plantar fascia thickness was decreased by 0.06 ± 0.33 mm SD after running and 0.03 ± 0.22 mm SD after walking. The difference between groups was not significant. CONCLUSION Although the parameters of this study did not produce significant changes in the plantar fascia thickness, a slightly higher change in the mean thickness of the plantar fascia in the running group deserves further investigation.

Sonography of Occult Rib and Costal Cartilage Fractures: A Case Series

OBJECTIVE The purpose of this case series is to describe the use of diagnostic ultrasound (US) in the detection of occult rib and costal cartilage fractures presenting as chest wall pain to a chiropractic clinic. CLINICAL FEATURES Three patients presented with chest wall pain and tenderness. Two of the patients presented with acute chest wall injury and 1 carried a previous diagnosis of rib fracture after trivial trauma 2 months earlier. INTERVENTION AND OUTCOMES Diagnostic US was selected as a non-ionizing imaging tool for these patients after negative digital radiography studies. All fractures were considered isolated as there was no associated injury, such as pneumothorax. Both of the acute cases were followed up to complete healing (evidence of osseous union) using US. All patients eventually achieved pain-free status. CONCLUSION In these cases, US was more sensitive than radiography for diagnosing these cases of acute rib and costal cartilage fractures. Early recognition of rib injury could avoid potential complications from local manipulative therapy.

Dynamic Ultrasonography of the Deep External Rotator Musculature of the Hip: A Descriptive Study

No detailed reports exist describing the methodology of ultrasound image acquisition of the deep external rotator muscles of the hip. Because gluteal pain and sciatica are common, ultrasound may be a useful dynamic imaging adjunct in the evaluation of these patients.

Clinical and Sonographic Evaluation of a Lower Extremity Angioleiomyoma in a 52-Year-Old Woman

OBJECTIVE The purpose of this case study is to describe the role of sonographic examination in the initial evaluation of an angioleiomyoma and to discuss the characteristic findings associated with this soft tissue mass. CLINICAL FEATURES A 52-year-old woman presented with a large, tender, erythematous mass on the anterolateral aspect of her right knee. Sonographic examination revealed a highly vascular mass within the subcutaneous tissues. Differential considerations included benign soft tissues masses such as angioleiomyoma and hemangioma. INTERVENTION AND OUTCOMES Surgical consultation was recommended. Excisional biopsy was performed. Histopathological examination confirmed the diagnosis of angioleiomyoma. CONCLUSION Although ultrasonographic findings of a superficial soft tissue mass may be nonspecific, when a highly vascular, well-defined, slow-growing mass is present, angioleiomyoma should be included in the differential diagnosis.

Ultrasound appearance and dynamic evaluation of variant long head of the biceps tendon anatomy with MRI correlation.

Many variants of the long head of the biceps tendon exist but their appearance has not been documented with ultrasonography (US). We describe a case of variant LHB anatomy that was visualized by magnetic resonance imaging and confirmed with US. Additionally, US was useful to exclude instability of the LHBT. To the best of our knowledge, this variant appearance of the LHBT has not been previously described with US. Considering that shoulder US is routinely performed clinically, knowledge of the appearance of variant LHBT anatomy may be useful.RiassuntoEsistono molte varianti del tendine del capo lungo del bicipite, ma il loro aspetto non è stato documentato con ecografia (US). Descriviamo un caso di variante anatomica del LHBT visualizzata con risonanza magnetica e confermata con gli US. Inoltre, gli US sono stati utili per escludere l’instabilità del LHBT. Per quanto a nostra conoscenza, questa variante del LHBT non è stata descritta in precedenza con gli US. Considerando che l’ecografia della spalla viene eseguita di routine nella pratica clinica, la conoscenza della variante anatomica del LHBT può essere utile.

Aneurysmal Bone Cyst Presenting as a Pathologic Fracture in a 12-Year-Old Football Player

OBJECTIVE The purpose of this report is to describe a case of an aneurysmal bone cyst presenting as a pathologic fracture in a young athlete. CASE REPORT A 12-year-old patient presented to a chiropractic teaching clinic with a 1-week history of posterior neck pain and stiffness following a helmet-to-helmet collision in football practice. Cervical spine radiographs were taken. Lateral view radiograph demonstrated a pathologic fracture through a lytic, expansive lesion in the posterior arch of C7 with mild subluxation of the C7/T1 apophyseal joints and angulation of the C7/T1 disk space. Based upon these findings, additional diagnostic imaging was ordered. Findings on advanced imaging studies included the following: On computed tomography, the C7 lesion showed medullary destruction, cortical thinning and expansion, and a horizontally oriented fracture through the spinous and lamina. Magnetic resonance imaging studies for sagittal T2 and contrast-enhanced T1-weighted magnetic resonance images revealed fluid/fluid levels in the C7 spinous and peripheral enhancement with contrast. OUTCOME The patient was referred to a local hospital for treatment. The lesion was treated with resection of the posterior arch, and an aneurysmal bone cyst was confirmed histologically. The patient developed a kyphotic deformity at the site of resection and cervical instability. A subsequent fusion was performed. CONCLUSION Aneurysmal bone cysts are rare lesions. In this case, the initial traumatic history masked the underlying pathology. Although rare, pathologic fracture should be considered in cases of vertebral fracture in young patients.

Sonographic diagnosis of an acute Stener lesion: a case report.

This case report describes the use of diagnostic ultrasound to diagnose a Stener lesion in a patient who presented for conservative care of thumb pain following a fall on an outstretched hand. Conventional radiographic images demonstrated an avulsion fracture at the ulnar aspect of the base of the first proximal phalanx. Diagnostic ultrasound revealed a torn ulnar collateral ligament of the thumb that was displaced proximal to the adductor aponeurosis, consistent with a Stener lesion. Dynamic imaging with ultrasound confirmed displacement of the fully torn ligament. Surgical repair followed the diagnosis. Diagnostic ultrasound in this case provided an accurate diagnosis obviating further imaging. This allowed an optimal outcome due to early intervention.SommarioIl caso che presentiamo descrive l’uso dell’ecografia nella valutazione della lesione di Stener in un paziente che si è presentato con pollice dolorante, a seguito di caduta a mano tesa. Le immagini radiografiche convenzionali avevano mostrato una frattura da avulsione dell lato ulnare della base della falange prossimale. La diagnosi ecografica ha rivelato una rottura completa del legamento collaterale ulnare metacarpo-falangeo del pollice, ribaltato sull’ aponeurosi dell’adduttore (lesione di Stener). L’imaging dinamico con ecografia ha confermato il ribaltamento del legamento lacerato. In seguito alla diagnosi è stata eseguita riparazione chirurgica. In questo caso la valutazione ecografica si è rivelata utile per una diagnosi accurata, evitando ulteriori indagini ed ha permesso di ottenere un risultato ottimale con l’intervento immediato.

Diagnostic Ultrasonography of an Ankle Fracture Undetectable by Conventional Radiography: A Case Report

OBJECTIVE The purpose of this study is to present diagnostic ultrasonography assessment of an occult fracture in a case of persistent lateral ankle pain. CLINICAL FEATURES A 35-year-old woman presented to a chiropractic clinic with bruising, swelling, and pain along the distal fibula 3 days following an inversion ankle trauma. Prior radiographic examination at an urgent care facility was negative for fracture. Conservative care over the next week noted improvement in objective findings, but the pain persisted. INTERVENTION AND OUTCOME Diagnostic ultrasonography was ordered to assess her persistent ankle pain and showed a minimally displaced fracture of the fibula 4 cm proximal to the lateral malleolus. The patient was referred to her primary care physician and successfully managed with conservative care. CONCLUSION In this case, diagnostic ultrasonography was able to identify a Danis-Weber subtype B1 fracture that was missed by plain film radiography.