Rajesh Botchu

Acute symptomatic calcific discitis in adults: a case report and review of literature.

Symptomatic calcific discitis has been reported in the paediatric population but is a rare entity in adults with only eight cases reported in the English literature. We present a case of adult calcific discitis presenting with acute onset back pain. Radiographs and CT demonstrated central T11–T12 disc calcification with diffuse marrow oedema on subsequent MRI. The patient was referred to our spinal oncology unit due to the extensive marrow oedema as a possible underlying primary bone tumour. Review of the CT confirmed an end-plate defect with herniated calcific nucleus pulposus with no underlying bone lesion. Features were in keeping with acute calcific discitis. The patient was treated symptomatically and made an uneventful recovery. We discuss the characteristic imaging features seen on radiograph, CT and MRI and review the current literature. Calcific discitis is a self-limiting pathology requiring symptomatic management only. Radiologists need to be aware of this rare entity as it can occur in adults and may be mistaken for a more sinister pathology such as infective discitis or a bone tumour and lead to further unnecessary imaging or invasive procedures.

So-Called Fibrohistiocytic Tumours

Fibrohistiocytic tumours are surrounded by controversy in their origin; its detailed description is beyond the scope of the current chapter. It is a popular term in the imaging literature, describing a lesion with histiocytic and fibroblastic appearances. It is categorised according to its malignant potential into (1) benign and (2) intermediate fibrohistiocytic lesions. Tenosynovial giant cell tumours have more in common with the descriptive category of fibrohistiocytic lesions than with true synovium.

Ganglion cyst arising from the transverse acetabular ligament (TAL): a rare cause of entrapment of the anterior branch of the obturator nerve. Case report and review of the literature

The transverse acetabular ligament is an unusual location for ganglion cysts. Only a few cases have been reported in the literature. They can be asymptomatic and represent an incidental finding or can cause an atypical pattern of hip joint/groin pain. We report a case of ganglion cyst arising from the TAL causing entrapment of the anterior branch of the obturator nerve with associated acute denervation of the abductor longus (AL), adductor brevis (AB), and gracilis muscles.

A cost-saving measure for ultrasound-guided musculoskeletal injections

We wish to highlight a novel cost-saving measure that we have introduced in our institution while performing ultrasound-guided musculoskeletal injections (MSKI). MSKI are relatively safe procedures, with a low risk of serious complication. Like other ultrasound-guided procedures, MSKI require aseptic technique and appropriate preparation of the ultrasound probe to prevent contamination of the injection site. Contamination of the injection site by both ultrasound probes and ultrasound gel has been reported [1, 2]. Different techniques have been reported to provide a sterile ultrasound probe surface, including commercially available ultrasound probe covers, sterile gloves and transparent dressings [3–5]. A number of probe covers are commercially available (e.g. ultrasound probe cover, Fannin UK LTD, Swandicote, DE12 7DT UK, probe cover, 365 Healthcare, Worcestershire WR9 9AX and ultrasound probe cover, Vygon UK LTD, Swindon, SN25 4DL). The use of sterile gloves has also been described using various techniques, including the use of either the whole glove or a single finger portion of the glove [4]. The former technique involves multiple manoeuvres to fasten the fingers of the glove and invariably leads to the accumulation of air pockets. The latter technique provides “probe only” protection, leaving the cord unsterile and a potential source for contamination. Similarly, the use of transparent sterile adhesive dressings provides “probe only” protection and has been described with the use of surgical gowns to extend the sterile field [5]. At our institution, the dressing packs used for MSKI contain a sterile disposal bag which we use as a modified probe cover. The content of the packs is shown in Fig. 1a (Synergy Health, Lancashire, PR7 7NB, UK). The dressing pack is CE marked and costs €0.61 per pack (GBP£0.54). Nonsterile ultrasound gel is placed directly on the probe surface and the bag is then unfolded over the probe by the operator wearing sterile gloves. The bag is then loosely twisted around the lead which extends the sterile field to include the cord (Fig. 1b, c). The use of additional sterile coupling gel on the surface of the covered probe is dependent on operator preference. The use of the disposal bag, which is otherwise disposed of, eliminates an additional cost of either a separate commercially available probe cover, additional set of gloves or transparent dressing. We perform approximately 2200 ultrasound-guided MSKI annually. To provide a price comparison, the ultrasound probe cover costs €1.73 (GBP£1.54, Fannin UK LTD) in our institution, whilst sterile gloves cost €0.78 per pair (GBP£0.69). The use of a commercially available probe cover adds approximately €3818 (GBP£3388) annually to the cost of MSKI in our institution. Although not in common use in our institution, the use of sterile gloves as a modified probe cover would potentially add approximately €1715 (GBP£1518) to the cost of MSKI. Given the ongoing financial constraints within our health system, it is prudent to remain conscious of procedural costs and consider innovative cost-saving ideas when treating patients where possible.

Intrasynovial spindle cell lipoma of the deep flexor of the middle finger causing intermittent carpal tunnel syndrome-case report and review of the literature.

Carpal tunnel syndrome (CTS) represents the most common entrapment neuropathy of the upper extremity. Intermittent CTS has been reported in the surgical literature and usually, related to masses associated to flexor tendons. We describe a patient with an intrasynovial lipoma involving the deep flexor of the middle finger causing intermittent CTS and snapping on flexion–extension. La sindrome del tunnel carpale (CTS) rappresenta la neuropatia da intrappolamento più comune dell’arto superiore. La CTS intermittente è stata riportata nella letteratura chirurgica e, di solito, in relazione alle masse associate ai tendini flessori. Descriviamo un paziente con un lipoma intrasinoviale che coinvolge il flessore profondo del dito medio che causa CTS intermittente e che si spezza sull’estensione della flessione.

Metaphyseal burst sign: A secondary sign on MRI of subchondral insufficiency fracture of the knee

To describe a novel secondary sign of subchondral insufficiency fracture of the knee, metaphyseal burst sign (soft tissue oedema in the meta‐epiphyseal region of the affected condyle).

Radiography and Computed Tomography

The imaging evaluation of a patient with a suspected soft tissue tumor requires a methodical approach that recognizes the benefits and limitations of the numerous imaging techniques that are available today. Consideration must be given to the financial costs and invasiveness of each technique balanced against the diagnostic reward. The temptation to routinely employ every technique in all patients should be resisted. Similarly, no examination should be reported in isolation without knowledge of relevant clinical details and results of prior investigations. Where possible, the prior investigations should be available for review, as the appreciation of the significance of a new observation may well depend upon a retrospective review of the previous studies [24].

Undifferentiated/Unclassified Sarcoma

Soft tissue sarcomas (STSs) represent a broad and complex group of mesenchymal lesions with a range of differentiation. The current 2013 World Health Organisation (WHO) classification of soft tissue tumours (Fletcher et al., WHO classification of tumours of soft tissue and bone IARC Press; Lyon, 2013) reflects the better understanding gained with advances in immunohistochemical analysis and cytogenetic and molecular genetic characterisation of STSs. There are over 50 subtypes of STS (Reichardt P, Future Oncol 10:s19–27, 2014).

Iatrogenic intratendinous ganglion cyst of the extensor digitorum tendon following intravenous cannulation

Peripheral venous cannulation is one of the most commonly performed medical procedures in hospital medicine. The dorsal metacarpal veins are typically used for cannulation as they are easily accessible. We present the first case of an iatrogenic intratendinous ganglion cyst of the extensor digitorum tendon of the middle finger following intravenous cannulation.SommarioIl posizionamento di cateteri venosi periferici è una delle procedure mediche più frequentemente eseguite negli ospedali. Le vene dorsali del metacarpo sono spesso utilizzate perché di facile accesso. Presentiamo il primo caso di cisti gangliare iatrogenica dell’estensore del terzo dito secondaria a cannulazione venosa.

A diagnostic approach to popliteal fossa masses

There is a myriad of potential mass lesions that occur in the popliteal fossa, which present as palpable masses or are found incidentally on imaging. With a thorough knowledge and understanding of the appearances and locations of these different entities, one can narrow the differential diagnoses in the majority of cases. This will eliminate unnecessary additional investigations and enable a more rapid management. We present a review of frequently encountered and less common entities using an anatomical sieve, with the aim of providing a diagnostic approach to popliteal fossa masses.