Bharti Khurana

Magnetic resonance imaging-guided percutaneous biopsy of musculoskeletal lesions.

BACKGROUND Bone, soft-tissue, and articular lesions are often well visualized by magnetic resonance imaging. Our goal was to evaluate the diagnostic performance of magnetic resonance imaging-guided biopsies of selected musculoskeletal lesions. METHODS In this retrospective case series, forty-five consecutive biopsies were performed in an open mid-field 0.5-T interventional magnetic resonance imaging unit with a real-time guidance system. The biopsies were performed at twenty bone, eighteen extra-articular soft-tissue, and seven intra-articular soft-tissue sites. The main reasons for using magnetic resonance imaging guidance were the need to improve lesion conspicuity compared with that provided by other imaging modalities, the need for site-specific targeting within the lesion, and the need for real-time guidance. Samples were obtained with fine-needle aspiration, core-needle biopsy, or a combination of these techniques. An independent reference standard was used to confirm the final diagnosis. Diagnostic performance was evaluated on the basis of the diagnostic yield (the proportion of biopsies yielding sufficient material for pathological evaluation) and diagnostic accuracy (sensitivity, specificity, positive predictive value, and negative predictive value). Complications were identified as well. RESULTS The diagnostic yield was 91% (forty-one of forty-five biopsies yielded sufficient material for a diagnosis) overall, 95% (nineteen of twenty) for the bone lesions, 94% (seventeen of eighteen) for the extra-articular soft-tissue lesions, and 71% (five of seven) for the intra-articular soft-tissue lesions. With regard to the diagnostic accuracy, the sensitivity was 0.86, the specificity was 1.00, the positive predictive value was 1.00, and the negative predictive value was 0.76 in the overall group. The respective values were 0.92, 1.00, 1.00, and 0.86 for the bone lesions; 0.77, 1.00, 1.00, and 0.57 for the extra-articular soft-tissue lesions; and 1.00, 1.00, 1.00, and 1.00 for the intra-articular soft-tissue lesions. There was one complication: exacerbation of neuropathic pain related to a biopsy of a peripheral nerve sheath tumor. CONCLUSIONS Magnetic resonance imaging-guided percutaneous biopsies of musculoskeletal lesions for which other imaging modalities might be inadequate have a good diagnostic performance overall. The performance can be very good for bone lesions, moderate for extra-articular soft-tissue lesions, and fair for intra-articular soft-tissue lesions.

ACR Appropriateness Criteria® acute trauma to the knee

More than 500,000 visits to the emergency room occur annually in the United States, for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiographs are not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographs ordered without missing a clinically significant fracture. Although a fracture is seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with a fall or twisting injury who have focal tenderness, effusion, or inability to bear weight, radiographs should be the first imaging study obtained. If the radiograph shows no fracture, MRI is best for evaluating for a suspected meniscus or ligament tear, or the injuries from a reduced patellar dislocation. Patients with a knee dislocation should undergo radiographs and an MRI, as well as an angiographic study such as a fluoroscopic, CT, or MR angiogram. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures, by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Traumatic Finger Injuries: What the Orthopedic Surgeon Wants to Know

Traumatic elbow injuries are commonly encountered in the emergency department setting, but their complexity and clinical significance often go unrecognized at the initial evaluation. Initial imaging in patients with elbow trauma should not only help identify major injuries that require immediate intervention but also allow detection of other, often more subtle injuries that may lead to instability or poor functional outcomes if appropriate treatment is delayed. Awareness and detection of these injuries may be improved by a better-developed and more intuitive understanding of the mechanisms that underlie the most common injury patterns. Ideally, such understanding should prompt appropriate early use of advanced imaging techniques. Traumatic elbow injuries should be described in the radiology report within the context of their clinical significance and their implications for management, information that is often best captured by the injury grading and classification systems used by the orthopedic surgery community. This article reviews the relevant anatomy and functional stability of the elbow and discusses common traumatic elbow injury patterns, including elbow dislocations as well as fractures of the distal humerus, radial head and neck, coronoid process, and olecranon. Less commonly encountered injury constellations that are clinically significant are also described. Injury patterns are explained in the context of the responsible force mechanism by using three-dimensional modeling and animation, with emphasis on the functional impact of associated secondary bone and soft-tissue injuries. The utility of cross-sectional imaging modalities such as computed tomography and magnetic resonance imaging in the acute care setting is discussed, and specific imaging guidelines are provided. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.333125176/-/DC1.

Abbreviated MRI for patients presenting to the emergency department with hip pain

OBJECTIVE The objective of our study was to assess the diagnostic performance of two abbreviated hip MRI protocols--coronal STIR images only and coronal STIR with coronal T1-weighted images--as compared with a full hip MRI protocol in patients presenting to the emergency department (ED) with hip pain and negative radiographic findings. MATERIALS AND METHODS The cohort included 385 patients (277 females, 108 males; mean age, 61 years; age range, 16-99 years) who underwent MRI within 1 month of negative radiographs obtained for ED evaluation of hip pain between January 2000 and March 2009. MR examinations were graded independently by two musculoskeletal fellowship-trained emergency radiologists for detection of fracture, avascular necrosis (AVN), and muscle injury in three subsets: coronal STIR images only; coronal STIR images and coronal T1-weighted images; and the full examination. RESULTS MRI detected findings suspicious for fracture in 42% (162/385) of patients, for AVN in 9% (33/385), and for muscle injury in 35% (134/385). The sensitivity and specificity of STIR alone in raising concern for fracture was 99% (220/223) for both readers, with small incremental benefits of adding coronal T1-weighted images. For AVN, specificity was 100% (28/28) with STIR alone, but the addition of coronal T1-weighted images provided substantial benefit by increasing sensitivity from 85% (28/33) to 97% (32/33). For muscle injury, sensitivity and specificity exceeded 95% (128/134) for both abbreviated examinations. CONCLUSION An abbreviated MRI protocol including coronal STIR and coronal T1-weighted images has high sensitivity and specificity for fracture, AVN, and muscle injury in ED patients presenting with hip pain and negative radiographs.

Simplified Diagnostic Algorithm for Lauge-Hansen Classification of Ankle Injuries

Ankle injuries occur in a predictable sequence, allowing a logical understanding of their classification once the injury mechanism is recognized. The Lauge-Hansen classification system was developed on the basis of the mechanism of trauma and is useful for guiding treatment. Three radiographic views of the ankle (anteroposterior, mortise, and lateral) are necessary to classify an injury with the Lauge-Hansen system. Two additional criteria are also necessary: the position of the foot at the time of injury and the direction of the deforming force. Because understanding the mechanism of trauma is fundamental to classifying the injury, three-dimensional movies were assembled for each classification, showing the sequence of ligament rupture and bone fractures that occurs with each type of traumatic mechanism. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.322115017/-/DC1.

What the emergency radiologist needs to know about treatment-related complications from conventional chemotherapy and newer molecular targeted agents

Emergency departments (ED) are increasingly utilized by oncology patients for disease- and treatment-related issues. With the increased use of new molecular targeted therapy (MTT) and conventional chemotherapeutic regimens, oncology patients present with a range of adverse treatment effects, some of which reveal characteristic injury patterns and imaging appearances. Knowledge of these imaging findings is critically important for early detection and prompt management in oncology patients. In this article, we present a brief review of conventional chemotherapeutic and new MTT regimens as well as address adverse reactions that bring oncology patients to the ED.

Traumatic Thoracolumbar Spine Injuries: What the Spine Surgeon Wants to Know

The Thoracolumbar Injury Classification and Severity Score (TLICS) is a scoring and classification system developed by the Spine Trauma Study Group in response to the recognition that previous classification systems have limited prognostic value and generally do not suggest treatment pathways. The TLICS provides a spine injury severity score based on three components: injury morphology, integrity of the posterior ligamentous complex (PLC), and neurologic status of the patient. A numerical score is calculated for each category, with a lower point value assigned to a less severe or less urgent injury and a higher point value assigned to a more severe injury requiring urgent management. The total score helps guide decision making about surgical versus nonsurgical management. The TLICS also emphasizes the importance of magnetic resonance imaging in evaluating PLC injury and acknowledges that the primary driver of surgical intervention is the patients neurologic status. Knowledge of PLC anatomy and its significance is essential in recognizing unstable injuries. Signs of PLC injury at computed tomography include interspinous distance widening, facet joint widening, spinous process fracture, and vertebral subluxation or dislocation. Familiarity with the TLICS will help radiologists who interpret spine trauma imaging studies to effectively communicate findings to spine trauma surgeons. The complete article is available online .

Pelvic Ring Fractures: What the Orthopedic Surgeon Wants to Know

Treating trauma patients with displaced pelvic fractures requires a multidisciplinary approach at a designated trauma center to reduce morbidity and mortality. Immediate recognition of pelvic ring disruption and determination of pelvic stability are critical components in the evaluation of such patients. Stability is achieved by the ability of the osseoligamentous structures of the pelvis to withstand physiologic stresses without abnormal deformation. The supporting pelvic ligaments, including the posterior and anterior sacroiliac, iliolumbar, sacrospinous, and sacrotuberous ligaments, play a crucial role in pelvic stabilization. Radiologists should be familiar with the ligamentous anatomy and biomechanics relevant to understanding pelvic ring disruptions, as well as the Young and Burgess classification system, a systematic approach for interpreting pelvic ring disruptions and assessing stability on the basis of fundamental force vectors that create predictable patterns. This system provides an algorithmic approach to interpreting images and categorizes injuries as anterioposterior (AP) compression, lateral compression, vertical shear, or combined. Opening and closing of the pelvis from rotational forces result in AP compression and lateral compression injuries, respectively, whereas vertical shear injuries result from cephalad displacement of the hemipelvis. AP and lateral compression fractures are divided into types 1, 2, and 3, with increasing degrees of severity. Knowledge of these injury patterns leads to prompt identification and diagnosis of other subtle injuries and associated complications at pelvic radiography and cross-sectional imaging, allowing the orthopedic surgeon to apply corrective forces for prompt pelvic stabilization.

Proximal Femoral Fractures: What the Orthopedic Surgeon Wants to Know

Each year, more than 250,000 hip fractures occur in the United States, resulting in considerable patient mortality and morbidity. The various types of adult proximal femoral fractures require different treatment strategies that depend on a variety of considerations, including the location, morphologic features, injury mechanism, and stability of the fracture, as well as the patients age and baseline functional status. The authors discuss femoral head, femoral neck, intertrochanteric, and subtrochanteric fractures in terms of injury mechanisms, specific anatomic and biomechanical features, and important diagnostic and management considerations, including the diagnostic utility of imaging modalities. The authors review clinically important classification systems, such as the Pipkin, Garden, Pauwels, and Evans-Jensen classification systems, with emphasis on differentiating subchondral insufficiency fractures from avascular necrosis of the femoral head and typical subtrochanteric fractures from atypical (often bisphosphonate-related) subtrochanteric fractures. In addition, the authors describe the potential complications and management strategies for each fracture type on the basis of the patients age and physical condition. A clear understanding of these considerations allows the radiologist to better provide appropriate and relevant diagnostic information and management guidance to the orthopedic surgeon.

Stress fractures of the foot and ankle, part 1: biomechanics of bone and principles of imaging and treatment

A stress fracture is a focal failure of bone induced by the summation of repetitive forces, which overwhelms the normal bone remodeling cycle. This review, the first of two parts, discusses the general principles of stress fractures of the foot and ankle. This includes bone structure, biomechanics of stress applied to bone, bone remodeling, risk factors for stress fracture, and general principles of imaging and treatment of stress fractures. Cortical bone and trabecular bone have a contrasting macrostructure, which leads to differing resistances to externally applied forces. The variable and often confusing imaging appearance of stress fractures of the foot and ankle can largely be attributed to the different imaging appearance of bony remodeling of trabecular and cortical bone. Risk factors for stress fracture can be divided into intrinsic and extrinsic factors. Stress fractures subject to compressive forces are considered low-risk and are treated with activity modification and correction of any modifiable risk factors. Stress fractures subject to tensile forces and/or located in regions of decreased vascularity are considered high risk, with additional treatment options including restricted weight-bearing or surgery.