Kutsi Tuncer

Ultrasound-guided shoulder MR arthrography: comparison of rotator interval and posterior approach

PURPOSE The purpose of this study was to prospectively evaluate the two different ultrasound-guided injection techniques for magnetic resonance (MR) arthrography of the shoulder. METHODS AND MATERIALS This study included 100 patients [50 rotator interval group (n=50) vs. 50 posterior approach group (n=50)]. All procedures were performed by the same radiologist. The two injection techniques were compared. The discomfort during and after arthrography was evaluated. Extraarticular contrast media extravasation was graded according to the MRI findings. The number of injection attempts, effect of contrast media extravasation rate on diagnostic quality and procedure times were recorded. RESULTS There were no significant difference between the posterior and rotator interval puncture groups with regard to pain (P=.915), procedure times (P=.401) or attempt scores (P=.182). There were significantly more contrast media extravasations with rotator interval approach than posterior approach (P<.05). CONCLUSION Both techniques were successful and well tolerated by patients. Posterior injection technique provided a more effective route with decreased extravasation rate and easier approach compared to the rotator interval approach.

Anatomy, Variants, and Pathologies of the Superior Glenohumeral Ligament: Magnetic Resonance Imaging with Three-Dimensional Volumetric Interpolated Breath-Hold Examination Sequence and Conventional Magnetic Resonance Arthrography

The purpose of this review was to demonstrate magnetic resonance (MR) arthrography findings of anatomy, variants, and pathologic conditions of the superior glenohumeral ligament (SGHL). This review also demonstrates the applicability of a new MR arthrography sequence in the anterosuperior portion of the glenohumeral joint. The SGHL is a very important anatomical structure in the rotator interval that is responsible for stabilizing the long head of the biceps tendon. Therefore, a torn SGHL can result in pain and instability. Observation of the SGHL is difficult when using conventional MR imaging, because the ligament may be poorly visualized. Shoulder MR arthrography is the most accurately established imaging technique for identifying pathologies of the SGHL and associated structures. The use of three dimensional (3D) volumetric interpolated breath-hold examination (VIBE) sequences produces thinner image slices and enables a higher in-plane resolution than conventional MR arthrography sequences. Therefore, shoulder MR arthrography using 3D VIBE sequences may contribute to evaluating of the smaller intraarticular structures such as the SGHL.

Extra-articular contrast material leaks into locations unrelated to the injection path in shoulder MR arthrography

AbstractObjectivesTo evaluate the localisation, frequency and amount of extravasation in patients with extra-articular contrast material leak into locations unrelated to the injection path in shoulder magnetic resonance (MR) arthrography and associated shoulder disorders.MethodsThe sites of extravasation were determined on the shoulder MR arthrography of 40 patients. The extravasations were measured on three vertical planes of the MR arthrography. Sufficient joint distension was assessed according to the transverse diameters of the axillary recess on coronal MR images.ResultsExtravasation of the contrast material occurred through the subscapular recess, the synovium of the biceps, and the axillary recess. In four cases, extravasations were observed in more than one anatomic location. The most common site of extravasation was along the subscapularis muscle. Superior labrum anterior-posterior (SLAP) lesions were found to be most frequently associated with extravasations. The amount of extravasation was significantly higher in patients with adhesive capsulitis compared with the patients with a different diagnosis (p = 0.022).ConclusionsThe extravasations adjacent to the axillary recess do not always indicate glenohumeral ligament pathology. Massive subscapular extravasations were most frequently associated with adhesive capsulitis and SLAP lesions, and might be considered in the MR arthrography report.Key Points• Contrast material extravasation may reduce the diagnostic value of shoulder MR arthrography. • The extravasations may occur into locations unrelated to the injection path. • The extravasations adjacent to axillary recess can be misleading for HAGL lesion. • Massive subscapular extravasations were frequently associated with adhesive capsulitis and SLAP lesions.

An unusual cause of spinal compression in a young woman: cervical osteochondroma.

A 24-year-old woman presented to our clinic with weakness in the left arm of a few months’ duration. The cervical X-ray revealed no abnormalities. On physical examination, there was weakness in the C2 and C3 distribution on the left side. Our initial diagnosis was that of a disc lesion, and a magnetic resonance imaging (MRI) was performed. The MRI revealed a bony mass protruding from the left lamina of the vertebral body of C3 with a cortical edge compressing the C2 and C3 left spinal roots (Figure, Left and Right).

Can we use lower volume of local anesthetic for infraclavicular brachial plexus nerve block under ultrasound guidance in children

OBJECTIVES To determine if the infraclavicular brachial plexus block can be applied with lower volume of local anesthetic. DESIGN Randomised, double-blinded clinical trial. PATIENTS 60 patients aged 5-15years with ASA I-II who underwent emergent or elective arm, forearm or hand operations were included in the study. INTERVENTIONS Patients were divided into two groups randomly; standard volume local anesthetic administered group (Group S, n=30) and low volume anesthetic administered group (Group L, n=30). MEASUREMENT Postoperative pain scores, sensory and motor block durations were noted. MAIN RESULTS Pain scores (Wong-Baker Face Scale) were evaluated and the results were detected to be similar at all times (30min, 1, 2, 4, 8, 12, 24h). Durations of motor block were 168(±16) minutes and 268(±15) minutes in Group L and Group S respectively and the difference was statistically significant (p<0.001). Durations of sensory block were 385(±26) and 402(±39) in Group L and Group S respectively and no statistically significant difference was detected (p=0.064). CONCLUSION Similar block success, postoperative sensory block durations and pain scores could be obtained during infraclavicular brachial plexus in pediatric patients with lower local anesthetic volumes.

Comparison of Open Bankart Repair versus Modified Bristow Operation for the Treatment of Traumatic Recurrent Anterior Dislocation and Capsular Laxity of the Shoulder.

OBJECTIVE The purpose of this study was to compare the results of open Bankart repair versus those of modified Bristow operation in patients with recurrent anterior dislocations of the shoulder, the last of which was caused by a minor trauma. MATERIALS AND METHODS This study included 38 patients (34 (89.5%) male and 4 (10.5%) female) who presented recurrent dislocation of the shoulders with capsular laxity and who underwent an open Bankart repair or a modified Bristow operation. The mean age of the patients was 29.6 years (range, 17-60 years). The mean follow-up period was 5.5 years (range, 35 months to 9 years). A total of 25 patients (65.8%) underwent an open Bankart repair, whereas 13 (34.2%) underwent a modified Bristow operation. The treatment results were assessed using the Rowe score for instability. RESULTS Of the 38 shoulders assessed, 24 (63.1%) were right shoulders and 14 (36.9%) were left shoulders. Furthermore, 26 (68.4%) were the dominant shoulders of the patients, and 12 (31.6%) were the non-dominant shoulders. The mean time from the first dislocation was 3.8 years (range, 10 months to 11 years). The age at which the first shoulder dislocation occurred was 20 years or younger in 7 cases (18.4%), 21-30 years in 22 cases (57.9%), 31-40 years in 6 cases (15.8%) and 41 or older in 3 cases (7.9%). The patients had experienced 4-10 recurrent dislocations in 15 cases (39.5%), 10-20 recurrent dislocations in 10 cases (26.3%) and 20 or more recurrent dislocations in 13 cases (34.2%). The mean Rowe score was 85.6 following open Bankart repair and 81.9 following modified Bristow. No significant difference was observed between these good and excellent Rowe scores following the open Bankart repair and the modified Bristow operation (p>0.05). CONCLUSION Proper patient selection for the open Bankart repair and the modified Bristow operation is crucial. When the proper patients have been selected for these procedures, both produce satisfactory results for the treatment of patients with capsular laxities.

Salter-Harris Type III and Type IV Combined Fracture of the Distal Femoral Epiphysis: A Case Report

Distal femoral physeal fractures are not common but have a high rate of complications. They generally follow one of the patterns described in the Salter-Harris classification. We present a case of combination of Salter-Harris type III and type IV injury. Our case was a 15-year-old boy who had a motor vehicle accident. There was swelling, ecchymosis, severe pain, and valgus deformity, because of medial proximal fracture fragment, on the left knee. We deemed that Salter-Harris type III and type IV combination fracture in our case has not been previously reported. We prepared this paper in consideration of its contribution to the literature.

Huge Bursitis Associated With Scapular Osteochondroma Presenting as a Giant Mass of the Chest Wall: A Case Presentation

Figure 1. (A-B) Three-dimensional computed tomography reveals a bone lesion on the ventral surface of the left scapula, compatible with a pedunculated osteochondroma. We present a case of huge scapulothoracic bursitis associated with scapular osteochondroma detected via computed tomography (CT) and magnetic resonance imaging (MRI) The bursa presented as a giant cystic mass on CT scan. A 19-year-old female patient presented with a giant left-sided posterolateral chest wall mass and left scapular elevation. She had a 4-month history of mild pain in the posterolateral aspect of the left chest wall. She did not participate in any sports activities and had no limitations in function of the left shoulder. The patient had no history of trauma or systemic disease. On physical examination, a w 20 cm w 30 cm fluctuant mass was palpable on the left side of the chest wall along the medial border of the left scapula. Plain radiographs showed an osseous mass arising from the ventral aspect of the left scapula. CT (performed with a 256-slice dual-source multidetector) revealed a mushroom-shaped solitary exostosis with a short stalk attached to the ventral surface of the left scapula (Figure 1). CT also showed a giant, welldefined hypodense lesion measuring approximately 8 cm w 15 cm w 25 cm between the scapula and the chest wall. MRI with and without intravenous gadolinium showed the mass to be a huge bursitis confining an osseous mass extending from the ventral aspect of the left scapula (Figure 2A-D). The cartilage cap was less than 1 cm. The lesion was diagnosed as benign osteochondroma with huge scapulothoracic bursitis. Surgical resection (Figure 3A-B) with histopathologic examination confirmed the lesion to be a typical osteochondroma with reactive bursitis. The patient had a good recovery without neurologic or functional deficits. Osteochondroma is the most frequently encountered primary bony tumor and consists of a cartilage cap that arises from the bone surface. Pain is rare and occurs secondary to pressure on the surrounding soft tissues, underlying bursitis, fracture due to trauma,

The clinical and radiological importance of extraarticular contrast material leakage into adjacent synovial compartments on ankle MR arthrography in patients with OCD and anterolateral impingement

PURPOSE To evaluate the tibiotalar joint capacity and the localisation, frequency and amount of extravasation in patients with extraarticular contrast material leakage into adjacent synovial compartments on ankle magnetic resonance (MR) arthrography. MATERIALS AND METHODS Sites of extravasation were determined in the ankle MR arthrograms of 69 patients. Thirty-four patients without extraarticular contrast material leakage into locations unrelated to the injection path were included as a control group. Volumetric measurements of extraarticular contrast material leakage and the tibiotalar joint capacity were performed on a three dimensional (3D) volume measurement workstation. RESULTS Extravasation of contrast material occurred through the anterior, posterior, and anterolateral recesses of the tibiotalar joint. The most common site of extravasation was along the flexor hallucis longus tendon synovium (24.6%). The amount of extravasation was significantly higher in patients with ankle osteochondritis dissecans (OCD) than in patients with a different diagnosis (p=0.039). Loose bodies were detected in all OCDs patients with insufficient tibiotalar joint distention. CONCLUSIONS Connections between the ankle joint and neighboring synovial compartments can decrease the diagnostic value of ankle MR arthrography examinations due to inadequate joint distention. Large injection volumes should be used for ankle MR arthrography of patients with OCD (especially OCDs patients with loose body) and impingement syndrome.

Spinal meningioma causing cervicothoracic rotoscoliosis.

An 86-year-oldwoman patient was admitted to our neurosurgery department with neck and thoracic back pain for 2 years. Neurological examination was normal. Magnetic resonance imaging was performed. Magnetic resonance images showed meningioma at cervical spinal cord (Fig. 1). In addition, computed tomography image showed cervicothoracic rotoscoliosis associated with the spinal meningioma (Fig. 2). Spinal meningiomas are the second-most common intradural extramedullary spinal tumor. They can occur at any location throughout the spine, but the common location is the thoracic region. Symptom-related spinal meningiomas include motor-sensory deficits, pain, and rarely sphincter dysfunction. The presence of a spinal cord tumor can cause rotoscoliosis. It may be because of muscle denervation and weakness caused by the involvement of the anterior horn cells or a flexed posture that opens the spinal canal in an