Paul D. Clifford

Value of radiographs in the initial evaluation of nontraumatic adult heel pain.

Background: Adult patients with nontraumatic plantar heel pain often present to orthopaedic surgeons for evaluation. A thorough history and physical examination are often sufficient for diagnosis, yet radiographs usually are ordered during the initial evaluation. The purpose of this study was to evaluate the value and cost-effectiveness of these radiographs. Methods: A retrospective chart and radiographic review of 157 consecutive adults (215 heels) presenting with nontraumatic heel pain was done to evaluate the utility of routine radiographs in the initial evaluation. Results: The most common diagnosis was plantar fasciitis (80.9%, 174 of 215). Radiographs were normal in (17.2%, 37 of 215), and incidental radiographic findings were observed in 81.4% (175 of 215). The most common incidental findings were plantar calcaneal spurs (59.5%, 128 of 215) and Achilles spurs (46.5%, 100 of 215). Only (2%, 4 of 215) of all patients had abnormal findings that prompted further evaluation. Conclusions: Routine radiographs are of limited value in the initial evaluation of nontraumatic plantar heel pain in adults and were not necessary in the initial evaluation. Radiographs should be reserved for patients who do not improve as expected or present with an unusual history or confounding physical findings.

Intravascular papillary endothelial hyperplasia (Masson’s tumor) presenting as a triceps mass

Abstract Intravascular papillary endothelial hyperplasia (IPEH) is a nonneoplastic reactive endothelial proliferation most commonly located in the skin or subcutaneous tissues although it has been reported in multiple locations throughout the body. We present a case of intravascular papillary endothelial hyperplasia presenting as a soft tissue mass in the triceps muscle. IPEH is not well-described in the radiologic literature.

Comparison of MRI and local anesthetic tendon sheath injection in the diagnosis of posterior tibial tendon tenosynovitis.

Background: The modalities currently available to clinicians to confirm the clinical suspicion of posterior tibial tendinitis include MRI, CT, sonography, tenography, and local anesthetic tendon sheath injections. There are no reports in the literature comparing local anesthetic tendon sheath injection to MRI as tools for diagnosing posterior tibial tenosynovitis. Methods: The authors reviewed the records of all patients with stage 1 posterior tibial tendon dysfunction between the dates of September 1, 2001, to November 21, 2004. Fifteen patients (17 ankles) had a local anesthetic injection into the posterior tibial tendon sheath and MRI for clinically suspected tenosynovitis of the posterior tibial tendon. Results: Seventeen (100%) of 17 ankles had complete relief of symptoms after the local anesthetic tendon sheath injections. Fifteen (88%) of 17 ankles had abnormally increased fluid signal within the posterior tibial tendon sheath seen on MRI. Two of two ankles (100%), after having negative MRI findings, had complete relief with a local anesthetic tendon sheath injection. In addition, conservative treatment failed in these two patients, and they subsequently had tenosynovectomy with gross confirmation at surgery of inflammatory changes within the tendon sheath. These two patients had complete symptom relief after tenosynovectomy. Conclusions: Local tendon sheath injections and MRI are both reliable diagnostic tools. Injection of the posterior tibial tendon is an accurate, safe, and sensitive modality useful in patients in whom MRI studies are negative in the face of continued clinical suspicion.

Imaging of Tarsal Navicular Disorders A Pictorial Review

The tarsal navicular is a bone within the midfoot that plays a critical role in maintaining the arch of the foot. This bone is clinically relevant because it may be affected by a wide array of pathologies. Our approach includes a detailed description of the imaging characteristics and disorders affecting the tarsal navicular. Organization includes (a) normal imaging, (b) accessory ossicles, (c) coalition, (d) fractures, (e) Kohler’s disease, (f) osteonecrosis, (g) osteochondral lesions, (h) arthropathies, and (i) tumors. The purpose of this article is to discuss normal variants and pathological processes that can affect the tarsal navicular, with emphasis on the often-overlooked imaging findings.

Benign and malignant tumors of the foot and ankle

Pain and focal masses in the foot and ankle are frequently encountered and often initiate a workup including imaging. It is important to differentiate benign lesions from aggressive benign or malignant lesions. In this review, multiple examples of osseous and soft tissue tumors of the foot and ankle will be presented. Additionally, the compartmental anatomy of the foot and ankle will be discussed in terms of its relevance for percutaneous biopsy planning and eventual surgery. Finally, a general overview of the surgical management of benign, benign aggressive and malignant tumors of the foot and ankle will be discussed.

Isolated long-head triceps brachii tendon avulsion in a surfer detected at MR imaging

We report a case of a rare isolated avulsion of the long head of the triceps tendon detected at magnetic resonance (MR) examination occurring in a 35-year-old male surfer. Isolated long-head triceps tendon avulsions have rarely been reported and, to our knowledge, the MR findings have not previously been described in the world literature.

Instability of the First Metatarsal-Cuneiform Joint: Diagnosis and Discussion of an Independent Pain Generator in the Foot

Background: First metatarsocuneiform (MC) instability is recognized as a pathologic contributor to hallux valgus. There are no studies identifying the first MC joint as an independent pain generator in the foot that may require surgical arthrodesis for its management. Materials and Methods: The authors reviewed the records of all patients with this newly described pathology in the first MC joint. There were 61 patients with 85 feet who underwent a fluoroscopically guided local anesthetic injection into the first metatarsocuneiform joint to assess pain relief. Patients complaints, physical exam findings, treatment decisions, patient characteristics, and radiographic findings were evaluated. Results: Seventy-nine percent of patients (67/85) injected had relief of their symptoms. Eight or these 67 patients were eventually treated with first MC arthrodesis with complete relief of symptoms. The average time from onset of symptoms to presentation was 21 (range, 1 to 72) months. Eighty-five percent of feet (72/85) had multiple previous diagnoses. Radiographic plantar widening of the first M-C joint on weightbearing views was inconsistent with pathology. Conclusion: The first MC joint is an independent pain generator in the foot that can have variable presentations. Radiographic data can often be helpful, but clinical exam findings are paramount in the diagnosis. Fluoroscopically-guided long acting local anesthetic injections of this joint are helpful in the diagnosis, especially in the patient with multiple possible pain generators in the foot and ankle. Failure to recognize the first MC joint as a source of pain may lead to delay in treatment, misdiagnosis, and mistreatment of foot pathology. Level of Evidence: IV, Retrospective Case Series

Basic imaging and differential diagnosis of kienböck’s disease

Imaging serves an important role in the diagnosis and classification of Kienbock’s disease. The four-stage system proposed by Lichtman et al. in 1977 is an imaging-based classification system, which has significant implications for treatment planning. Whereas the initially proposed Lichtman classification was based primarily on radiographical osseous findings, advancements in the understanding of computed tomography (CT) and magnetic resonance imaging (MRI) features of Kienbock’s disease have allowed incorporation of these two modalities into the classification system. The appearance of imaging features of Kienbock’s disease mirrors the natural course of the disease—progressing from marrow edema of the lunate (stage I) to trabecular sclerosis (stage II), to lunate collapse (stage III), and ultimately to secondary degenerative changes of the wrist. MRI has proven to be useful for the detection of early Kienbock’s disease, which is frequently not demonstrated on radiography and CT. It is also useful for assessing and staging the articular cartilage involvement and monitoring the revascularization and response to treatment.

Orthopaedic case of the month: a 51-year-old man with a painless wrist mass.

A 51-year-old right-hand dominant man was evaluated for an enlarging, painless left wrist mass of 2 months duration. The patient reported no recent injury or antecedent trauma and denied any local neurologic symptoms, fevers, chills, or changes in weight. Physical examination revealed a nontender, 3 9 2-cm firm, mobile mass overlying the volar aspect of the left distal ulna. There was no rash or other identifiable overlying skin changes, and the lesion did not transilluminate. The patient had normal strength and ROM, and sensation to light touch was intact in all three nerve distributions. There was a negative Tinel’s sign and the mass was nonpulsatile with a normal vascular examination. AP and lateral views of the left wrist (Fig. 1) and MRI of the wrist (Fig. 2) were obtained. Based on the history, physical examination, and imaging studies, what is the differential diagnosis at this point?