Ferdinando Draghi

Overload syndromes of the knee in adolescents: Sonographic findings.

Overload syndromes are caused by repetitive microtrauma, and the knee joint is most frequently affected in adolescents. The reason for this is that the knee joint is engaged in almost all sports activities. Pathologies related to the anterior aspect of the knee are: femoropatellar pain, jumpers knee syndromes, Osgood-Schlatter disease, Sinding-Larsen-Johansson syndrome and patellar stress fractures; to the medial aspect: semimembranous tendon enthesopathy and pes anserinus bursitis; to the lateral aspect: iliotibial band syndrome (runners knee), popliteus and femoral biceps tendon enthesopathy; to the posterior aspect: fabella syndrome and medial gastrocnemius muscle tendon enthesopathy. Sonography plays a central role in the diagnosis and can also evaluate the evolution of diseases. This method is well accepted by the patients and by their parents, it does not involve exposure to X-rays and it is inexpensive. US imaging should, therefore, be considered a first-line imaging diagnostic technique in functional overuse syndromes of the knee.

Contrast enhancing agents in ultrasonography: Clinical applications

INTRODUCTION As ultrasound remains a poorly sensitive method, echocontrast agents make a real difference. At least 29 echocontrast agents are currently on trial worldwide; their chemical composition, mechanisms of action and possible clinical applications are different. The state of the art of echocontrast agents is discussed: their established applications, those expected in the near future and finally their hypothetical, ideal applications. POTENTIAL CLINICAL APPLICATIONS An extravascular and a vascular domain can be considered. The former includes the gastrointestinal tract and body cavities--both the normal (bladder, uterus, tubes and so on) and the abnormal (abscesses, fistulas, pericardium, peritoneum and so on) ones. Echocontrast agents can: (1) create or improve an acoustic window; (2) distend some organs and fill them with a liquid, with homogenous attenuation of the ultrasound beam; (3) displace the air-containing intestinal loops; (4) depict the walls, the shape and the contours of a normal or abnormal cavity; (5) detect abnormal communications, fistulas and drainages; and (6) evaluate the amount of fluid in the pleural, pericardial or peritoneal cavities. As for vascular applications, this domain sees the highest number of echocontrast agents on trial or on the market. The best know of them are: Levovist (Schering AG, Berlin, Germany), BR1 (Bracco, Milan, Italy) and EchoGen (Abbott, USA). All these act by enhancing arteries, veins and capillaries. The clinical applications validated in clinical trials mainly regard studies in intracranial and neck vessels and the vascularity of upper and especially lower limbs of renal vessels. Tumor macrovascularity (and in the future, hopefully microvascularity) can also be studied in parenchymatous and/or glandular organs, as well as in intra- and extra-abdominal parenchymatous organs in the periskeletal soft tissues. Clinical validation has also been obtained in the follow-up of tumors submitted to ablation therapy (chemoembolization, ethanol injection, thermal ablation) and in echocardiography, both for morphological studies in the cardiac cavities and for the cardiac wall perfusion. CONCLUSIONS In a subgroup of 513 out of 1275 patients examined Europe-wide, the contrast agent Levovist increased the diagnostic confidence from 27.4 +/- 22.5 to 77.2 +/- 22.5%. Such data encourage further trials to validate current preliminary results.

Carpal tunnel: Normal anatomy, anatomical variants and ultrasound technique.

The carpal tunnel is an osteofibrous canal situated in the volar wrist. The boundaries are the carpal bones and the flexor retinaculum. In addition to the medial nerve, the carpal tunnel contains nine tendons: the flexor pollicis longus, the four flexor digitorum superficialis and the four flexor digitorum profundus. Ultrasound (US) study of the carpal tunnel generally involves short-axis imaging of the tendons, and in the presence of disease, long-axis imaging and dynamic maneuvers are added. There are numerous reports of anatomical variants of the wrist involving vessels, nerves, tendons and muscles, and they can all be studied by US. Some are particularly relevant from a clinical point of view and will therefore be accurately described. The anatomy is complex, and the US operator should therefore be thoroughly familiar with the normal anatomy as well as the anatomical variants that may have a role in the pathogenesis of carpal tunnel syndrome or influence treatment.

Interventional musculoskeletal ultrasonography: Precautions and contraindications.

In recent years ultrasonography (US) has emerged as the imaging technique of choice for guiding diagnostic and therapeutic procedures including those related to the musculoskeletal system. However, the absence of ionizing radiation and the elevated safety of the method must not lead us to forget that there are precautions and contraindications to keep in mind, which are crucial to the protection of both the patient and the physician.Among these precautions it is first of all essential to obtain the patients accurate clinical history including current medication, particularly if it involves drugs influencing the blood clotting, and information related to possible allergies. The patient should furthermore receive detailed information concerning the procedure (sterile precautions as well as possible side-effects of the drugs which will be injected). In addition to this, there must be a close contact between the radiologist and the patients general physician (GP) in order to obtain the best possible result of the procedure.

Ultrasound of the elbow: Examination techniques and US appearance of the normal and pathologic joint

Ultrasound studies are frequently requested for the work-up of patients with local elbow pain, which is generally caused by overuse syndromes, trauma, inflammatory diseases, or neuropathies. The technique used to examine this joint will vary to some extent depending on the precise location of the pain and other clinical findings. The aim of this article is to describe the standard technique used for elbow ultrasound, the normal anatomy of the joint, and the appearance on ultrasound of normal elbow anatomy and the alterations associated with some of the more common disorders affecting this joint.

Hoffa’s fat pad abnormalities, knee pain and magnetic resonance imaging in daily practice

AbstractHoffa’s (infrapatellar) fat pad (HFP) is one of the knee fat pads interposed between the joint capsule and the synovium. Located posterior to patellar tendon and anterior to the capsule, the HFP is richly innervated and, therefore, one of the sources of anterior knee pain. Repetitive local microtraumas, impingement, and surgery causing local bleeding and inflammation are the most frequent causes of HFP pain and can lead to a variety of arthrofibrotic lesions. In addition, the HFP may be secondarily involved to menisci and ligaments disorders, injuries of the patellar tendon and synovial disorders. Patients with oedema or abnormalities of the HFP on magnetic resonance imaging (MRI) are often symptomatic; however, these changes can also be seen in asymptomatic patients. Radiologists should be cautious in emphasising abnormalities of HFP since they do not always cause pain and/or difficulty in walking and, therefore, do not require therapy. Teaching Points • Hoffa’s fat pad (HFP) is richly innervated and, therefore, a source of anterior knee pain. • HFP disorders are related to traumas, involvement from adjacent disorders and masses. • Patients with abnormalities of the HFP on MRI are often but not always symptomatic. • Radiologists should be cautious in emphasising abnormalities of HFP.

Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging

AbstractPlantar fascia (PF) disorders commonly cause heel pain and disability in the general population. Imaging is often required to confirm diagnosis. This review article aims to provide simple and systematic guidelines for imaging assessment of PF disease, focussing on key findings detectable on plain radiography, ultrasound and magnetic resonance imaging (MRI). Sonographic characteristics of plantar fasciitis include PF thickening, loss of fibrillar structure, perifascial collections, calcifications and hyperaemia on Doppler imaging. Thickening and signal changes in the PF as well as oedema of adjacent soft tissues and bone marrow can be assessed on MRI. Radiographic findings of plantar fasciitis include PF thickening, cortical irregularities and abnormalities in the fat pad located deep below the PF. Plantar fibromatosis appears as well-demarcated, nodular thickenings that are iso-hypoechoic on ultrasound and show low-signal intensity on MRI. PF tears present with partial or complete fibre interruption on both ultrasound and MRI. Imaging description of further PF disorders, including xanthoma, diabetic fascial disease, foreign-body reactions and plantar infections, is detailed in the main text. Ultrasound and MRI should be considered as first- and second-line modalities for assessment of PF disorders, respectively. Indirect findings of PF disease can be ruled out on plain radiography. Teaching Points • PF disorders commonly cause heel pain and disability in the general population.• Imaging is often required to confirm diagnosis or reveal concomitant injuries.• Ultrasound and MRI respectively represent the first- and second-line modalities for diagnosis.• Indirect findings of PF disease can be ruled out on plain radiography.

Sonographic anatomy of the ankle

Ankle sonography is one of the most commonly ordered examinations in the field of osteoarticular imaging, and it requires intimate knowledge of the anatomic structures that make up the joint. For practical purposes, the examination can be divided into four compartments, which are analyzed in this pictorial essay: the anterior compartment, which includes the tibialis anterior, extensor hallucis longus, and extensor digitorum longus tendons; the accessory peroneus tertius tendon; and the extensor retinaculum; the medial compartment (tibialis posterior, flexor digitorum longus, and flexor hallucis longus tendons; the flexor retinaculum; the medial collateral—or deltoid—ligament, and the neurovascular bundle); the lateral compartment (peroneus longus, peroneus brevis, and peroneus quartus tendons; superior and inferior peroneal retinacula, lateral collateral ligament); and the posterior compartment (Achilles tendon, plantaris tendon, Kagar’s triangle, superficial, and deep retrocalcaneal bursae). Scanning techniques are briefly described to ensure optimal visualization of the various anatomic structures.RiassuntoL’esame ecografico della caviglia è tra gli esami più richiesti nell’ambito dell’ecografia osteoarticolare; ne deriva la necessità di una conoscenza approfondita delle strutture anatomiche che la compongono. L’approccio ecografico per lo studio della caviglia è, per scopi pratici, organizzato per comparti; si analizzano nel presente pictorial essay le strutture del comparto anteriore (tendine tibiale anteriore, tendine estensore lungo dell’alluce, tendine estensore lungo delle dita, tendine peroneo tertius, retinacolo degli estensori), del comparto mediale (tendine tibiale posteriore, tendine flessore lungo delle dita, tendine flessore lungo dell’alluce, retinacolo dei flessori, legamento collaterale mediale o deltoideo, fascio vascolo-nervoso), del comparto esterno (tendini peronei breve e lungo, tendine peroneo quarto, retinacolo superiore ed inferiore dei peronei, legamento collaterale esterno), del comparto posteriore (tendine d’Achille, tendine del muscolo plantare, triangolo di Kager, borse sinoviali calcaneali superficiale e profonda). Si riporta inoltre qualche breve cenno di tecnica ecografica necessaria per l’ottimale visualizzazione delle strutture descritte.

Interventional musculoskeletal US: an update on materials and methods

Pain is one of the most common causes of reduced productivity. The annual cost of health-related reductions in productivity has been estimated at approximately 225 billion dollars in the United States alone. Ultrasound-guided locoregional infiltration procedures have frequently been shown to offer economical, effective, lasting relief of pain. In-depth familiarity with the equipment (probes and needles) and techniques used to perform these procedures are fundamental for safe, effective treatment. In fact, depending on the characteristics of the patient and the clinical problem, the approach and technique may have to be modified to simplify the procedure and ensure better results. Up-to-date knowledge of the drugs used for these infiltrations (indications, how they are used) is equally important. Our aim is to provide an update on the techniques and materials used in interventional musculoskeletal ultrasonography based on a review of the most recent literature as well as on our personal experience.RiassuntoIl dolore è una delle cause più frequenti di riduzione della produttività. Si stima che i costi della riduzione della produttività legata a problemi di salute siano di circa 225 miliardi di dollari per anno, nei soli Stati Uniti. Tra i trattamenti che hanno più frequentemente dimostrato di possedere caratteristiche di economicità, efficacia e durevolezza nella riduzione del dolore vi sono indubbiamente i trattamenti infiltrativi loco-regionali eco-guidati. E’ fondamentale avere una conoscenza approfondita delle apparecchiature (sonde e aghi) e delle diverse tecniche per raggiungere il sito di iniezione efficacemente ed in sicurezza. Infatti, in base alle caratteristiche del paziente e al problema clinico, può essere necessario cambiare approccio e tecnica al fine di raggiungere più semplicemente il miglior risultato. Non meno importante è un costante aggiornamento sulla corretta selezione e impiego delle sostanze da iniettare. Ci proponiamo pertanto di realizzare un update sulle tecniche e sui materiali utilizzati in ecografia interventistica muscoloscheletrica, alla luce sia della letteratura più recente che della nostra personale esperienza.

Muscle injuries: ultrasound evaluation in the acute phase.

Muscle injuries can be classified as extrinsic or intrinsic injuries as well as contusions and lacerations, and clinical assessment is composed of the history and physical examination. Diagnostic imaging, particularly ultrasound (US) examination, is essential to a correct assessment of the severity of the injury and to exclude important complications as these two elements influence treatment decisions, prognosis and time to return to unrestricted physical activity. This paper presents the main clinical and US features of acute muscle injuries.RiassuntoI traumi muscolari possono essere classificati in estrinseci, contusioni e lacerazioni, e intrinseci. Il riconoscimento avviene attraverso l’anamnesi e l’esame clinico. L’imaging, in particolare l’ecografia, é di fondamentale importanza per valutare correttamente la gravità del trauma e per escludere le principali complicanze, i due elementi che incideranno di più sul tipo di trattamento a cui sarà sottoposto il paziente, sulla prognosi e sulla tempistica del ritorno all’attività fisica. In questo articolo vengono presentate le principali caratteristiche cliniche ed ecografiche dei traumi muscolari acuti.