Rate of abnormal osteoarticular radiographic findings in pediatric patients

OBJECTIVE

The objective of our study was to assess the rate of abnormal radiographic findings in the most frequent osteoarticular locations of traumatic injury in a pediatric population.

SUBJECTS AND METHODS

During two periods of 12 weeks each, all patients admitted to the pediatric emergency department for osteoarticular trauma who underwent radiography were prospectively included in this study. A connection was drawn between the rate of abnormal radiographic findings for the seven most frequently radiographed locations and the clinical findings.

RESULTS

Of 3128 locations of trauma in 2470 children, only 22% of the radiographic examinations were considered to reveal abnormal findings. In decreasing order, the hand and fingers, the ankle, the wrist, the knee, the elbow, the foot and toes, and the forearm were the most frequently examined locations. The rate of abnormal findings was 25.7% for the hand and fingers, 9.0% for the ankle, 42.5% for the wrist, 9.5% for the knee, 33.3% for the elbow, 18.3% for the foot, and 43.2% for the forearm. When only the direct sign of fracture was taken into account, these rates decreased for the ankle and knee to 2.6% and 1.9%, respectively. There was always a significant link between the degree of clinical suspicion and the rate of abnormal radiographic findings. However, fewer than 50% of the cases with high clinical suspicion of fracture were radiographically confirmed.

CONCLUSION

It appears necessary, especially in cases of lower limb trauma, to evaluate clinical tests, including the implementation of the Ottawa ankle rules, to reduce the number of unnecessary radiographic examinations. This reduction will improve some parameters of children's quality of life and will significantly decrease the cost of emergency care.

Intestinal involvement in Buerger's disease

Thromboangiitis obliterans characteristically affects small- and medium-sized vessels of the limbs in young smokers. There is some controversy about the existence of visceral localizations of the disease. The case of a patient with a well-established diagnosis of thromboangiitis obliterans who presented with mesenteric ischemia is described and the literature concerning mesenteric involvement in the disease is reviewed.

Evaluation of the prenatal diagnosis of limb reduction deficiencies. EUROSCAN Study Group

Ultrasound scans in the mid-trimester of pregnancy are now a routine part of antenatal care in most European countries. Using data from registries of congenital anomalies a study was undertaken in Europe. The objective of the study was to evaluate prenatal detection of limb reduction deficiencies (LRD) by routine ultrasonographic examination of the fetus. All LRDs suspected prenatally and all LRDs (including chromosome anomalies) confirmed at birth were identified from 20 Congenital Malformation Registers from the following 12 European countries: Austria, Croatia, Denmark, France, Germany, Italy, Lithuania, Spain, Switzerland, The Netherlands, UK and Ukrainia. These registries are following the same methodology. During the study period (1996-98) there were 709,030 births, and 7,758 cases with congenital malformations including LRDs. If more than one LRD was present the case was coded as complex LRD; 250 cases of LRDs with 63 (25.2%) termination of pregnancies were identified including 138 cases with isolated LRD, 112 with associated malformations, 16 with chromosomal anomalies and 38 non chromosomal recognized syndromes. The prenatal detection rate of isolated LRD was 24.6% (34 out of 138 cases) compared with 49.1% for associated malformations (55 out of 112; p<0.01). The prenatal detection of isolated terminal transverse LRD was 22.7% (22 out of 97), 50% (3 out of 6) for proximal intercalary LRD, 8.3% (1 out of 12) for longitudinal LRD and 0 for split hand/foot; for multipli-malformed children with LRD those percentages were 46.1% (30 out of 65), 66.6% (6 out of 9), 57.1% (8 out of 14) and 0 (0 out of 2), respectively. The prenatal detection rate of LRDs varied in relation with the ultrasound screening policies from 20.0% to 64.0% in countries with at least one routine fetal scan.

Limb reconstruction surgery with external fixators--university hospital experience

We are describing 21 limb reconstruction procedures performed in 18 patients with the use of external fixators from 1996 to 1998. The average age of patients was 21, ranging from 1 to 50 years old. Indications for surgery included short limb, non-union, pseudoarthrosis and bone or soft tissue deformities. Average length obtained for cases of limb lengthening was 6 cm. All the seven clubfoot deformities in five children were fully corrected. Equinus deformity recurred in one foot and was treated with supramalleolar osteotomy. Out of the seven cases with infected nonunion and bone loss, three failed to achieve union and required additional bone grafting procedures. One patient with unilateral external fixator for the correction of tibia shortening developed valgus deformity.

Scintigraphic method for evaluating reductions in local blood volumes in human extremities

We introduce a new method for evaluating reductions in local blood volumes in extremities, based on the combined use of autologue injection of 99mTc-radiolabelled erythrocytes and clamping of the limb blood flow by the use of a tourniquet. Twenty-two healthy male volunteers participated in the experiment. Evaluation of one versus two scintigraphic projections, trials for assessment of the reproducibility, a comparison of the scintigraphic method with a water-plethysmographic method and registration of the fractional reduction in blood volume caused by exsanguination as a result of simple elevation were carried out. No significant differences between results obtained by the use of one or two scintigraphic projections were found. The between-subject coefficient of variation was 14% in the lower limb experiment and 11% in the upper limb experiment. The within-subject coefficient of variation was 6% in the lower limb experiment and 6% in the upper limb experiment. We found a significant relation (r = 0.42, p = 0.018) between the results obtained by the scintigraphic method and the plethysmographic method. In fractions, a mean reduction in blood volume of 0.49+0.14 (2 SD) was found after 1 min of elevation of the lower limb and a mean reduction of 0.45+/-0.10 (2 SD) after half a minute of elevation of the upper limb. We conclude that the method is precise and can be used in investigating physiologic and pathophysiologic mechanisms in relation to blood volumes of limbs not subject to research previously.

The effectiveness of the haemodialysate Solcoseryl for second-intention wound healing in horses and ponies

Second-intention healing of limb wounds in horses is often problematic. Solcoseryl is a protein-free, standardized dialysate/ultrafiltrate (HD) derived from calf blood, which has been shown to improve healing in both animals and humans. The efficacy of HD in the healing of deep wounds in horses and ponies was investigated. Deep wounds of 20 by 35 mm were created on both metatarsi (skin, subcutis, periosteum) and on both femoral biceps muscles (skin, subcutis, muscle) of five horses and five ponies. The wounds on one side were treated with HD, four times a week during the period that the wounds were bandaged and once daily thereafter. The wounds on the other side were left untreated. In the first 4 weeks of the healing period HD stimulated healing but inhibited healing thereafter. This pattern was significant for all wound groups (P < 0.001). Because of this change in effect, the overall effect on wound healing over the entire period was not significant (P = 0.77). HD stimulated healing initially by provoking a greater initial inflammatory response, faster contraction and faster formation of granulation tissue. Subsequently, HD inhibited healing because it significantly delayed epithelialization and caused protracted inflammation. The effects of HD were most pronounced in the horses. Because this study distinguished between contraction and epithelialization, it could be shown that HD stimulated contraction but inhibited epithelialization. Therefore, HD is useful in horses for the treatment of deep wounds during the initial phase of healing by second intention, i.e. during the first weeks when wound contraction can be expected. Treatment should be ceased when epithelialization becomes predominant.

The role of bone scanning in severe frostbite of the extremities: a retrospective study of 88 cases

We performed a retrospective study of the results of two-phase technetium-99m hydroxymethylene diphosphonate bone scans in 88 patients with severe frostbite of the extremities. All patients were evaluated within 48 h after rewarming and all underwent a first bone scan (BS1) within 5 days after rewarming (median, day 2) (group 1). An excellent correlation was found between absence of tracer uptake in the phalanges and later amputation; this correlation was especially strong during the bone phase of the scans (specificity = 0.99, sensitivity = 0.96, positive predictive value = 0.92). Normal or high uptake in the phalanges was a reliable indicator of ultimate healing (negative predictive value = 0.99). The sensitivity of the examination was enhanced by performing a second scan (BS2) more than 5 days (median, day 8) after rewarming (group 2, n = 36). A comparative analysis of BS1 and BS2 demonstrated that some of the lesions continued to evolve between day 2 and day 8. This suggests that the lesions could still be modified during this period. On the basis of the findings it is recommended that bone scan be performed close to day 2 in all patients who present with lesions extending proximally to include the entirety of one or more phalanges. In the case of severe sepsis, the results of the first bone scan, BS1, can serve as an indication for emergency amputation. BS2 should be performed close to day 8 only if there is an area of low or absent uptake on BS1. It is concluded that scintigraphy is an excellent means of evaluating patients with severe frostbite of the extremities: as early as day 2 after the injury it can indicate whether amputation is necessary, and between days 2 and 8 it provides valuable information on the efficacy of treatment.

Bone infection in the bovine appendicular skeleton: a clinical, radiographic, and experimental study

Four hundred and forty-five bovines with bone infection of the appendicular skeleton were selected for clinical and radiographic assessment. A distinction was made between hematogenous and post-traumatic origin (wound/fracture). Bone infection was classified into four types according to the site of infection: type 1 is metaphyseal and/or epiphyseal osteomyelitis close to the growth plate; type 2 is primary subchondral osteomyelitis mostly accompanied by septic arthritis; type 3 is infectious osteoarthritis with subchondral osteomyelitis implicating that infection in the subchondral bone originates from the infection. Type 4 summarizes bone infections which can not be categorized in the previous groups. Hematogenous osteomyelitis is 3.2 times more frequent than post-traumatic osteomyelitis. Within the different groups, the relation of hematogenous to post-traumatic infection changed significantly. In type 1 infection the ratio was 5/1, in type 2 the ratio was 8/1 and in type 3 it was 3/1. Epiphyseal or metaphyseal osteomyelitis exhibited early radiographic bone changes, whereas with infection eminating from the joint, the bone lesions were detected later, because the bone was infected as a consequence of a primary septic arthritis. In smaller bones, severe and complete bone destruction was often present. Hematogenous bone infection never involved the entire diaphysis. Actinomyces pyogenes was discovered to be the main etiologic agent, whether or not combined with anaerobes. Bone fragments from the metaphysis of young calves were subjected to the effect of pure cultures of different bacteria. Radiographic changes to the structure of the bone were not identified within 2 weeks. Rapid radiographic changes in osteomyelitis cannot be explained by the direct effect of the bacteria on bone tissue in vivo. General infections of the lungs, disorders of the intestines and other internal organs were rarely responsible for osteomyelitis or septic arthritis. Osteomyelitis and infectious osteoarthritis is probably often induced by external and internal traumatic events to joints and bones in cattle.

Expandable endoprosthesis reconstruction in skeletally immature patients with tumors

Between September 1984 and January 1996, 32 expandable endoprostheses were used for limb reconstruction after resection of malignant bone tumors in patients who were skeletally immature. The 20 boys and 12 girls ranged in age from 3 to 15 years (mean, 9.7 years). One patient had a Stage IIA tumor, 22 patients had Stage IIB tumors, and seven patients had Stage III tumors according to the classification of the Musculoskeletal Tumor Society. There also were two patients with parosteal osteosarcomas. The histologic diagnosis was osteosarcoma in 23 patients and Ewing's sarcoma in nine. All patients except the patients with parosteal osteosarcoma received standard neoadjuvant therapy. Twenty-two Lewis Expandable Adjustable Prostheses, four modular Wright Medical prostheses, four modular Howmedica prostheses, and two Techmedica expandable prostheses were used. Thirteen patients died, two have no evidence of disease, and 17 are continuously disease free. Sixteen of 32 patients (50%) have not had an expansion procedure because of early death in 10 and early amputation in three. Three patients are waiting to undergo an expansion procedure. Sixteen of the 32 patients (50%) have undergone 32 expansion procedures, to a maximum of 9 cm, without any infection. To maintain range of motion before the expansion procedure, a complete resection of the pseudocapsule was done routinely. Fourteen of the 32 patients did not have complications. Eighteen of the 32 patients had 27 complications. All Lewis Expandable Adjustable Prosthesis endoprostheses and the two nonmodular Techmedica prostheses were associated with a large amount of titanium debris. The children's functional results were similar to the results reported for adults with an average Musculoskeletal Tumor Society rating of good to excellent at the knee, fair to good at the hip, and fair about the shoulder. Rehabilitation of the knee in very young patients (5-8 years) remains problematic and careful selection of patient and family is necessary. The Lewis Expandable Adjustable Prosthesis probably should be reserved for very young patients (5-8 years) and modular systems should be used for large preadolescent and adolescent children.

Results of bone scintigraphy in racing standardbred horses: 64 cases (1992-1994)

OBJECTIVE

To document anatomic patterns of scintigraphic uptake and related orthopedic disease associated with racing activity in Standardbred horses.

DESIGN

Retrospective study.

ANIMALS

64 Standardbred horses evaluated for lameness.

PROCEDURE

Medical records at the time of discharge were reviewed, and information regarding signalment; history; results of lameness examination, scintigraphy, and radiography; diagnosis; and treatment were obtained.

RESULTS

274 areas of increased radiopharmaceutical uptake were identified. Scintigrams of 218 limbs (106 forelimbs, 112 hind limbs) were available for review. Seventy-three (33%) scintigrams had increased radiopharmaceutical uptake associated with the proximal sesamoids, 46 of 106 (43%) fore-limb scintigrams had increased uptake associated with the third carpal bone, and 33 of 112 (33%) hind limb scintigrams had radiopharmaceutical uptake associated with the small tarsal bones. Forty-three of 218 (20%) scintigrams had increased uptake associated with the distal aspect of the third metacarpal and metatarsal bones. Abnormal scintigraphic uptake was bilateral in 91 of 139 (65%) forelimb locations and 99 of 134 (74%) hind limb locations with increased radiopharmaceutical uptake. The primary scintigraphically identified classifications of disease were exercise-induced bone remodeling, synovitis or arthritis, and soft-tissue avulsion from bone (66, 17, and 6% of areas with increased radiopharmaceutical uptake, respectively). Of 274 areas with increased radiopharmaceutical uptake, 244 (89%) were believed to be clinically important.

CONCLUSIONS AND CLINICAL RELEVANCE

Distinctive patterns of increased radiopharmaceutical uptake were identified that suggested Standardbred horses used for racing may have a predilection to develop orthopedic disease at specific sites that are distinct from those in Thoroughbreds used for racing and horses used for jumping activities.

Multiple osteolysis of peripheral extremities in a patient with adult T cell leukemia/lymphoma

A 67-year-old woman with severe pain in the peripheral extremities was admitted to our hospital. Radiography of the peripheral extremities revealed multiple osteolytic lesions. Antibody to human T cell leukemia virus type-I (HTLV-I) was positive, and right radial bone biopsy showed infiltration of adult T cell leukemic (ATL) cells. Irradiation therapy was effective in the osteolytic lesions. In the present case, elevation of IL-6 was detected, suggesting that IL-6 produced by ATL cells is related to their proliferation in the bone, and local osteolysis.

Effective elastic properties for lower limb soft tissues from manual indentation experiment

Quantitative assessment of the biomechanical properties of limb soft tissues has become more important during the last decade because of the introduction of computer-aided design and computer-aided manufacturing (CAD/CAM) and finite element analysis to the prosthetic socket design. Because of the lack of a clinically easy-to-use apparatus, the site and posture dependences of the material properties of lower limb soft tissues have not been fully reported in the literature. In this study, an ultrasound indentation system with a pen-size hand-held probe developed earlier by the authors was used to obtain the indentation responses of lower limb soft tissues. Indentation tests were conducted on normal young subjects with four females and four males at four sites with three body postures. A linear elastic indentation solution was used to extract the effective Young's modulus from the indentation responses. The determined modulus ranged from 10.4 to 89.2 kPa for the soft tissues tested. These results were in a similar range as those reported in the literature. The thickness of the lower limb soft tissues varied slightly with body posture changes. The Young's modulus determined was demonstrated to be significantly dependent on site, posture, subject and gender. The overall mean modulus of male subjects was 40% larger than that of female subjects. No significant correlation was established between the effective Young's modulus and the thickness of entire soft tissue layers.

Radiation exposure to personnel during examination of limbs of horses with a portable hand-held fluoroscopic unit

OBJECTIVES

To determine radiation exposure to personnel during fluoroscopic imaging of limbs of horses with a portable unit and to determine distance from the c-arm at which radioprotective clothing is not required.

DESIGN

Repeated-measures cohort study.

SAMPLE POPULATION

Part 1, 1 forelimb and 1 hind limb from each of 5 equine cadavers; parts 2 and 3, personnel involved during imaging of limbs of 5 and 9 horses, respectively.

PROCEDURE

Radiation exposure rates were mapped around the suspended c-arm of a portable fluoroscopy unit during imaging of various joints of equine cadaver limbs. During similar examinations in live horses, exposure rates to the fluoroscopist and assistant were measured. Mean duration for fluoroscopy of various joints was determined by observing an experienced fluoroscopist. Exposure to fluoroscopists and assistants per examination and per annum was estimated.

RESULTS

Radiation exposure rates were dependent on distance and direction relative to the c-arm and consistently highest on the tube side of the unit. Exposure was significantly greater than background amounts until approximately 4.7 m from the c-arm. During examination of live horses, exposure was highest to the fluoroscopist's hand nearest the tube. Typically, exposure to the fluoroscopist and assistant during carpal examination was 25 to 40 times greater than that for comparable radiographic examination. Annual exposure for fluoroscopists was more than twice the recommended maximum permissible dose.

CONCLUSIONS AND CLINICAL RELEVANCE

Fluoroscopic imaging of limbs of horses represents a major source of radiation exposure. Annual maximum permissible doses of radiation will be rapidly exceeded if required radioprotective clothing is not worn.

Evaluation of the patient with extremity trauma: an evidence based approach

This article reviews relevant literature to provide evidence based guidelines for the evaluation of patients with extremity trauma in the emergency department. The development of clinical decision rules for extremity trauma in the ankle and knee, and guidelines for obtaining postreduction radiographs of shoulder dislocations and nursemaid's elbows are discussed.

A 'one-stop' vascular clinic: initial experience of an out-patient immediate-access radioisotope limb blood flow service

The availability of an 'immediate-access' nuclear medicine service has facilitated the introduction of a 'one-stop' vascular clinic, enabling radioisotope limb blood flow and Doppler ankle:brachial index tests to be performed within 2 h of each other for new patient referrals. The test results are available to assist clinical management decisions during the same clinical session. A patient satisfaction survey was undertaken in 71 patients to assess their perspective of this service provision. Fifty-one (72%) patients returned the questionnaire. All respondents preferred to have attended the 'one-stop' clinic to having to return for investigations on a separate occasion. The patient satisfaction survey has identified patient perceived advantages of improved diagnostic efficiency, reduced number of visits, reduced patient worry and the minimization of patient travel costs. During the study period, 83% of allocated gamma-camera imaging slots were utilized, demonstrating that immediate-access nuclear medicine service provision linked to specific clinics can be a practicable solution to reducing waiting times for investigative tests. This is believed to be the first reported immediate-access nuclear medicine service, as opposed to the emergency investigations normally offered to clinically urgent requests.

Standardized CT examination of the multitraumatized patient

The aim of this study was to develop a standardized non-helical-CT protocol including head, body and proximal extremities in order to achieve a good time efficiency and diagnostic accuracy in the initial radiological evaluation of the multitraumatized patient. A total of 111 circulatory stable blunt trauma patients, brought in to a trauma level II-III hospital, were examined according to a standardized CT protocol. After examining the head with contiguous 10-mm slices without i.v. contrast medium injection, the trunk was examined with 10-mm slices every 30 mm through thorax-abdomen-pelvis with i.v. contrast medium enhancement (occasionally modified). All data in the medical reports were collected and used as "end-point", and the outcome of the CT examination was compared with this final diagnosis. Mean examination time was 20 min (range 12-32 min). In total, 55 head injuries, 89 thoracic injuries, 27 abdominal/pelvic injuries and 62 fractures were found. Computed tomography correctly identified the injuries, except one brain stem injury, one contusion/rupture of the heart, one hepatic injury, two intestinal injuries, eight vertebral injuries and one joint dislocation. A standardized non-helical-CT examination of the head and body may be achieved in 20 min. Its diagnostic accuracy was high, except for vertebral column injuries, which is why we recommend it as the method of choice for initial radiological examination of multitraumatized patients. When available, helical scanning would improve both examination speed and accuracy.

Radiation dosimetry for extremity radiographs

The energy imparted, epsilon, to a patient undergoing an extremity x-ray examination may be obtained from the dose-area product incident on the patient. Values of energy imparted can be subsequently converted into the corresponding effective dose, E, using an extremity specific E/epsilon ratio. In this study, an E/epsilon ratio of 3 mSv/J was used to convert values of energy imparted into the corresponding upper limit of adult effective doses for all types of extremity examinations. A modification factor, based on the patient mass, was employed to determine the corresponding extremity effective doses to pediatric patients undergoing extremity examinations. Representative clinical technique factors for six common extremity examinations (hand, forearm, elbow, ankle, tibia/fibula, knee) were used to determine the dose-area product and the corresponding values of energy imparted. For adult extremity x-ray examinations, values of energy imparted ranged from 55 microJ to 920 microJ, with the energy imparted to 1-y-old patients being a factor of about 20 lower. Upper limits of effective doses for adult extremity x-ray examinations ranged from 0.17 to 2.7 microSv, whereas the corresponding doses to 1-y-old patients were about a factor of three lower.

Massive localized lymphedema in the morbidly obese: a histologically distinct reactive lesion simulating liposarcoma

We report 14 cases of a soft tissue lesion in the limbs of morbidly obese adults that presents as a large mass and histologically simulates well-differentiated liposarcoma (WDL). Based on its distinctive clinical setting and morphologic identity to diffuse lymphedema we have termed this process massive localized lymphedema (MLL). All cases occurred in morbidly obese adults (mean weight 372 lbs; mean age 47 years). Women predominated (9 women; 5 men). The lesions affected the proximal medial aspect of the extremities (12 thigh; 2 arm) and were unilateral in all but two patients. Etiologically significant antecedent events include ipsilateral axillary lymphadenectomy in both patients with arm lesions, chronic lymphedema resulting from vein-stripping 10 years prior in one patient. inguinal lymphadenectomy for anal carcinoma in another patient, and significant blunt trauma to the inner thigh during a motor vehicle accident in a third patient. The tumors were long standing ( I-IO years) and extremely large (mean size 33.4 cm, 7408 g). Clinically, they were diffuse, ill-defined masses that histologically consisted of lobules of mature fat interrupted by expanded connective tissue septa. The constituents of the septa were fine, fibrillary collagen, edema fluid, and uniformly distributed fibroblasts. Clusters of capillaries were frequently found at the interface between fat and connective tissue. The widened septa simulated the fibrous bands of sclerosing WDL, but MLL lacks the degree of nuclear atypia seen in the former. The consistent clustering of reactive vessels at the interface between the fat and fibrous tissue also contrasted with WDL. Six patients experienced persistent or recurrent lesions within 10 months to 10 years. No aggressive growth or histologic progression was observed during this time, however. Awareness of the features of MLL is important to avoid misclassification of this reactive lesion with WDL.

[CT-phlebography. A new method for the diagnosis of venous thrombosis of the upper and lower extremities]

Spiral CT venography is a new method in vascular imaging, which is an accurate tool for the evaluation of deep venous thrombosis in the evaluation of deep venous thrombosis in the lower and upper extremity.

MATERIALS AND METHODS

102 lower extremities and 12 upper extremities were evaluated for deep vein thrombosis using spiral-CT-venography. The results were compared with findings of ascending venography, color coded duplex sonography and clinical follow up.

RESULTS

Spiral CT venography of the lower extremity showed a sensitivity of 100% and a specifity of 96%. The quality of venous opacification with CT venography compared with ascending venography was superior in all venous segments.

DISCUSSION

Spiral CT venography is a valuable tool for the detection of deep venous thrombosis. Advantages of the method are the reduction of the amount of contrast material necessary for opacification and the detection of perivascular soft tissue alterations. The application of CT venography is limited due to higher costs and radiation dosage.

[Free vascularized bone transplantation in the extremities]

There is a growing trend today which calls for reconstructing the loss of bigger bone parts in the area of extremities in a suitable manner. The microvascular bone transplantation for bridging bone defects is--admist other procedures--a distinct enrichment to preserve the extremities. This method of transplantation has the capability of surviving within a weakened transplant bed. Because of this capability one inevitably wants to know the criteria which determine the biological behaviour of the transplants. Furthermore, it is essential to known how this criteria can be best managed, considering the different indications and locations. The bone healing and bone hypertrophy of 81 patients who received vascularised bone transplantations have been examined with respect to different parameters. As the positive capacities of the vital transplants are almost exclusively dependent on the actual supply with blood, angiography have been undertaken during three months after surgery. 71 patients with a patent anastomosis after surgery have been evaluated. Differences in bone healing of the vascularised transplants have been observed in regard to the following parameter:--The tumor group showed a better rate of bone healing than those patients with trauma and congenital tibiapseudarthrosis.--The bone healing results of the group of younger patients were better than those of the group of older patients. Moreover the transplants without a history of infection were better compared with transplants with a history of infection. Clear differences of the fibula hypertrophy behaviour have been observed with respect to the following parameters: upper extremities < lower extremities, thigh < lower leg, longer transplants < shorter transplants, group of older patients (35-60 years) < group of younger patients (1-18 years), plates < screws.

[Contrast medium studies of the venous system]

PURPOSE

To give an overview of various diagnostic techniques and indications for phlebography in different parts of the body.

METHODS

Procedures of conventional phlebography of the lower and upper extremity and cavography are described and their indications in comparison to alternative techniques are discussed. The literature is reviewed with regard to specific advantages and disadvantages of the different methods.

RESULTS

Conventional phlebography with iodine contrast media is still considered to be the gold standard in many regards. The diagnosis of acute and chronic thrombotic disease, venous vascular occlusions, hemodynamic malfunctions and anatomic variants of the venous system can readily be established with contrast phlebography.

DISCUSSION

Main disadvantages of contrast studies of the venous system are radiation exposure and adverse effects of contrast media. Non-invasive methods such as ultrasound and MR-phlebography are becoming more and more popular and may replace venography. Other techniques such as CT-phlebography and the use of CO2 as contrast medium are under investigation. The latter can be indicated in the case of contraindications against iodine contrast media.

CONCLUSION

When choosing diagnostic methods for the venous system, their sensitivity and specificity for specific diagnoses and vascular territories have to be balanced against the risks and disadvantages.

Postoperative treatment of patients submitted to reconstruction with massive homoplastic grafting

Over the last 10 years at the Ist Orthopaedic Clinic of the Rizzoli Institute more than 350 cases of massive bone homoplastic cadaver-retrieved reconstruction were carried out, after bone tumor resection. We reported the postoperative management indicated to the patient to prevent complications and to improve functional results. The indications protocol includes time required for immobilization, motion, and partial and total loading; functional and radiographic results expected. Finally, these indications are specified for site of reconstruction and fixation chosen.

A novel gamma-sarcoglycan mutation causing childhood onset, slowly progressive limb girdle muscular dystrophy

Limb girdle muscular dystrophy is a heterogeneous group of disorders. One autosomal recessive subtype, LGMD2C, has been linked to chromosome 13, and is caused by gamma-sarcoglycan deficiency in muscle. This report describes a novel missense mutation identified in a large consanguineous Dutch family with LGMD. This mutation leads to reduction of gamma-sarcoglycan, and gives rise to a childhood-onset, slowly-progressive dystrophy.

[Osteosynthesis revision in war fractures]

The results of early conversion of war fractures by the application of AO osteosynthesis in A group (n = 32) of the injured, were compared with B group (n = 187) of injured, treated definitely with external fixator. There were statistical evaluations and X-ray observations of healing in both groups, as well as the appearances of the most frequent complications such as: Pintract infection, osteitis, pseudoarthrosis and reoperation. Statistically less significant appearance of complications in A group during 2nd and 6th month (p < 0.001) was observed. In 12th month of observation, these differences statistically disappeared. Healing observed by X-ray in 2nd, 6th and 12th month of observation were no statistically significant differences between the two observed groups.

Effect of copper supplementation on the evidence of developmental orthopaedic disease in pasture-fed New Zealand Thoroughbreds

The effect of copper status on the evidence of bone and cartilage lesions was investigated in 21 Thoroughbred foals. The foals and their dams were grazed on pasture containing 4.4-8.6 mg Cu/kg dry matter (DM). Four treatment groups were created by randomly allocating mares and their foals to either copper supplemented (0.5 mg Cu/kg liveweight (LW)/day), or control (pasture only) groups. This experimental design allowed the effect of copper supplementation of mare and foal to be examined independently. Parameters of bone and cartilage development were assessed in the foals both in vivo, and at post mortem at approximately age 150 days. Mare copper supplementation significantly (P<0.01) decreased radiographic indices of physitis in the distal third metatarsal bone of the foals at 150 days, and the prevalence of articular cartilage lesions (P<0.05). Articular cartilage lesions were minor in all foals, with no evidence of clinical developmental orthopaedic disease (DOD) in vivo, with the exception of minor radiographic changes assessed at post mortem. Copper supplementation of the foal had no effect on any of the bone and cartilage parameters. Copper supplementation of the mares did not abolish DOD in the growing foals, emphasising the probable multifactorial nature of this condition. However, mare supplementation may be a useful treatment regime on a farm where the incidence and severity of DOD are of concern.

Results of complete lymph node dissection in 83 melanoma patients with positive sentinel nodes

BACKGROUND

The technique of sentinel lymph node (SLN) biopsy for melanoma provides accurate staging information because the histology of the SLN reflects the histology of the entire basin, particularly when the SLN is negative.

METHODS

We combined two mapping techniques, one using vital blue dye and the other using radiolymphoscintigraphy with a hand-held gamma Neoprobe, to identify the SLN in 600 consecutive patients with stage I-II melanoma. The SLNs were examined using conventional histopathology and immunohistochemistry for S-100.

RESULTS

Eighty-three (13.9%) patients had micrometastatic disease in the SLNs. Thirty percent of patients with primary melanomas greater than 4.0 mm in thickness had positive SLNs, followed by 48 of 267 (18%) of patients with tumors between 1.5 mm and 4 mm, and 12 of 169 (7%) of those with lesions between 1.0 mm and 1.5 mm. No patient with a tumor less than 0.76 mm in thickness had a positive SLN. Sixty-four of the 83 SLN-positive patients consented to undergo complete lymph node dissection (CLND), and five of 64 (7.8%) of the CLNDs were positive. All patients with positive CLNDs had tumor thicknesses greater than 3.0 mm.

CONCLUSIONS

The rate of SLN-positive patients increases with increasing thickness of the melanoma. SLN-positive patients with primary lesions less than 1.5 mm in thickness may have disease confined to the SLN, thus rendering higher-level nodes free of disease, and may not require a CLND.

Reduction of "callbacks" to the ED due to discrepancies in plain radiograph interpretation

Retrospective and prospective chart review was conducted to study patient callbacks to the emergency department (ED) based on plain radiograph interpretation discrepancies between radiologists and emergency physicians before and after a continuous quality improvement (CQI) intervention. Patients who were called back to the ED because of radiograph interpretation discrepancies were retrospectively studied. These results were reviewed by a CQI team, which recommended greater communication and consultation. A prospective study was then performed. Before quality intervention, 0.7% of the patients were recalled; 0.4% required recall after quality assurance, a reduction of 42.9% (P = .0001). Emergency physicians in this study had a low percentage of patient recall due to discrepancies in radiologic interpretation. CQI further reduced this percentage. The proficiency of emergency physicians interpreting radiographs validates the current practice of emergency physicians rendering treatment based on their interpretations and supports the notion of emergency physicians billing for this service.

Dyggve-Melchior-Clausen syndrome without mental retardation (Smith-McCort dysplasia): morphological findings in the growth plate of the iliac crest

Dyggve-Melchior-Clausen syndrome without mental retardation (Smith-McCort dysplasia) (SM) has clinical and radiographic findings similar to those of Dyggve-Melchior-Clausen syndrome (DMC) except for mental retardation. Iliac crest biopsies from two patients with SM were examined. The lace-like appearance of the iliac crests, which is a characteristic radiological sign of SM and DMC, was caused by bone tissue deposited in a wavy pattern at the osteochondral junction. The growth plate showed abnormal enchondral ossification with no columnarization of chondrocytes. Electron microscopy demonstrated chondrocytes with dilated cisternae of rough endoplasmic reticulum containing fine granular or amorphous material, similar to those reported in cases of DMC. Thus, SM has pathologic changes in common with DMC as a rough endoplasmic reticulum storage disorder, even though the mental condition is different.

Proportional changes in body fluid with hemodialysis evaluated by dual-energy X-ray absorptiometry and transthoracic bioimpedance with particular emphasis on the thoracic region

Alterations in body composition during extracorporeal hemodialysis (HD) were investigated in 12 hemodialysis patients (9 males and 3 females, mean age 50 +/- 15 years) with a mean ultrafiltration of 2.6 +/- 1.0 L. Analysis was performed using a dual-energy x-ray absorptiometry technique (DXA), which measures 3 principal components of the body: fat mass (FM): lean body mass (LBM), i.e., all soft tissues excluding fat; and bone mineral content (BMC). These 3 components were calculated for the whole body and for different body regions (namely, the thorax, trunk, lower limbs, and upper limbs). The thoracic cage region could be defined manually, separately from the trunk, and its tissue composition was calculated. DXA analysis was performed concomitant with a measurement of the basal thoracic impedance (TFI) by bioimpedance cardiography prior to and 1 h after dialysis. We found a significant decrease in the total LBM, from 55.8 +/- 8.8 to 53.3 +/- 9.3 kg (p < 0.05), but no change in either the FM or BMC. Moreover, there was a disproportional reduction in the LBM in different regions, being significantly greater in the thorax (7.47 +/- 3.7%) than in the other body regions (trunk 4.3 +/- 2.0%, lower limbs 5.4 +/- 2.1%, and upper limbs 4.7 +/- 1.5%). Regarding bioimpedance, a stronger significant correlation was detected between the percentage changes in the TFI and the changes in thoracic fluid (r = 0.80, p < 0.01) than between the changes in the TFI and the changes in the total body fluid (r = 0.63, p < 0.01). The absolute values of the TFI were also significantly and negatively correlated to the thoracic lean mass to fat mass ratio, both before and after HD (r = 0.82, p < 0.001 and r = 0.86, p < 0.001, respectively). In conclusion, DXA is a very sensitive technique to detect fluid changes during HD in the thorax when the thoracic cavity is defined as a region of interest as well as for the whole body. The data also indicate an extracellular compartmental imbalance between different regions with a significantly greater change in the thoracic region. Transthoracic bioimpedance is a useful technique for evaluating the HD induced changes in the thoracic fluid, rather than total body fluid.

99Tcm-MDP scintigraphy in high-voltage electrical burn patients

In high-voltage electrical burn injuries (> 1000 V), it is difficult to identify the site and extent of non-viable deep tissue damage for debridement to avoid further tissue injury from wound infection and the risk of sepsis. This prospective study was designed to evaluate the usefulness of 99Tcm-methylene di-phosphonate (99Tcm-MDP) scintigraphy in detecting the extent of tissue injury and determining the level of amputation required for electrical burn patients. Over a 5 year period, 33 high-voltage electrical burn patients were studied. Blood flow and blood pool studies revealed absent perfusion in 37 limbs, all of which eventually were amputated. In addition to a routine three-phase bone scan, images were obtained at 30-60 min (early images) to evaluate whether soft tissue injury could be detected better at that time. For comparison of the detection rate from the early images and bone (delayed) images, 164 corresponding spot views of both images were reviewed. Eighty-three and 125 tissue necrotic lesions were demonstrated by the early images and bone images respectively. All of the 83 lesions found by the early images were more clearly identified by the bone images. All but one of the 125 lesions underwent surgical debridement or amputation. We concluded that the blood flow and blood pool images correlated well with the level of amputation required. The site and extent of tissue necrotic lesions can be clearly identified on 99Tcm-MDP bone scans. Because the early images were less sensitive in detecting tissue necrosis, we suggest that early imaging is not necessary.

Six cases positive for anti-centromere antibodies with ulcer and gangrene in the extremities

We report six cases that were positive for anti-centromere antibodies, with ulcer and gangrene in the extremities but mild or no skin thickening. The patients were five women and one man, and the mean age at onset of gangrene was 56 yr. Raynaud's phenomenon was found in five patients and calcinosis cutis in two patients. Three patients did not satisfy the criteria for systemic sclerosis and CREST syndrome in this study. Ulcer and gangrene occurred in the fingers in three patients, and in the fingers and toes in two patients. The gangrene was refractory to treatment, and amputation of fingers or toes was inevitable in five patients. Regardless of cutaneous lesion, the presence of anti-centromere antibodies may cause the same pathological presentation of vascular damage as seen in systemic sclerosis.

Reflex sympathetic dystrophy. An exaggerated regional inflammatory response?

Reflex sympathetic dystrophy (RSD) is a syndrome affecting an extremity after a minor trauma or operation. Currently, there is no consensus about the pathogenesis of RSD. The authors performed various clinical and experimental investigations, including studies of the effects of anti-inflammatory treatment, that support the hypothesis that RSD is the result of an exaggerated inflammatory response to injury or surgery.

Comparison of conventional and computed radiography: assessment of image quality and reader performance in skeletal extremity trauma

RATIONALE AND OBJECTIVES

Reader performance and image quality wee assessed for standard film, computed film, and computer monitor radiography viewing formats in the evaluation of skeletal extremity trauma.

MATERIALS AND METHODS

Three radiologists and three orthopedic surgeons interpreted 27 skeletal radiographs obtained with equivalent technical parameters. Readers evaluated standard film, computed film, and computer monitor formats randomly for fracture and soft-tissue abnormalities. Sessions were videotaped, and eye motion was recorded.

RESULTS

No statistically significant differences were found between image formats for true-positive or false-positive findings of trauma indicators. Findings were classified as false-negative based on eye position fixation times. Search errors (lesion not fixated) accounted for 21.7%, 20.6% and 17.1% of false-negative errors with the computer monitor, computed film, and standard film formats, respectively. Combined recognition errors and decision errors were 78.3%, 79.4%, and 82.9%, respectively. Viewing times were longest for the computer monitor images (P < .001). Image quality, contrast, and sharpness were rated highest for computed radiographs (P = .001). Radiologists had a higher true-positive decision rate than orthopedic surgeons (P = .03).

CONCLUSION

No statistically significant differences were seen in reader performance among viewing formats. The computed film format received the highest quality rating, and workstation viewing times were longest.

Image quality and the clinical radiographic examination

Image quality considerations in medical radiography are as diverse and complex as are the types of anatomy and pathologic conditions encountered in clinical practice. Nevertheless, certain basic concepts are central to the discussion of image quality in any radiographic examination. These concepts include the types of significant, or target, findings that are expected to occur and the anatomic background on which they are likely to appear. Physical parameters of radiographic systems, such as contrast, sharpness, and noise, act in unison in determining the final appearance of a radiograph and affect not only the portrayal of the expected pathologic condition but also that of the normal anatomy. Basic radiographic approaches in different clinical radiographic examinations can be derived from anticipated targets and backgrounds as well as from known physical determinants of image quality in radiography.

Limb defects in homozygous alpha-thalassemia: report of three cases

Homozygosity for the South-Asian alpha-thalassemia (--SEA/) deletion is a serious hematological condition that results, in most cases, in intrauterine or postnatal death due to anemia and severe hypoxia of prenatal onset. A relationship between congenital abnormalities and intra-uterine hypoxia has been postulated. However, since homozygosity for the (--SEA/) deletion is most common in underdeveloped countries where detailed autopsies are lacking, the incidence of congenital abnormalities among these babies has not been well delineated. We report on three newborn infants, homozygous for the (--SEA/) deletion, who were born with limb defects. We postulate that this combination is the result of prenatal hypoxia which may affect other fetal body organs. This should be taken into consideration when prenatal treatment of affected fetuses, with intrauterine blood transfusion, is suggested.

The arthropathy of fibroblastic rheumatism

Fibroblastic rheumatism (FR) is a relatively rare syndrome characterized by the association of multiple cutaneous nodules with polyarthritis. The unique histologic finding in the skin and synovium of patients with FR is a proliferation of myofibroblast-like cells within a background matrix of collagen. The occurrence of erosive arthritis has not been emphasized in previous descriptions of FR. We describe a patient with FR who presented with symmetric polyarthritis, skin thickening, and dermal nodules. Despite treatment with prednisone and D-penicillamine, he developed a progressive, destructive polyarthropathy that mimicked multicentric reticulohistiocytosis.

Prenatal sonographic diagnosis of congenital varicella infection--a case report

We report a case of fetal varicella infection following the diagnosis of maternal varicella infection at 13 weeks of pregnancy. Anomalies noted sonographically at 26 weeks' gestation included oligohydramnios, symmetrically impaired fetal growth, limb anomalies, a thin placenta, and widespread dystrophic calcification of the abdominal cavity and chest, including the lungs and myocardium. Some of these sonographic anomalies have been reported previously. However, to our knowledge, prenatal diagnosis of calcification of the lungs and myocardium has not been described.

Limb length discrepancy

The surgical management of LLD has gradually evolved from a time when patients were bedridden in traction for prolong periods of time to the point at which much of the treatment time is spent in mobility. Improved surgical techniques, such as percutaneous epiphysiodesis and distraction osteogenesis, have contributed greatly to the success of surgery for LLD. Factors affecting outcome and patient satisfaction must be weighed carefully before selecting treatment for LLD.

Radiological appearance of air introduced during equine regional limb anaesthesia

Twelve horses were injected intra-articularly into the metacarpophalangeal joint and extra-articularly in the region of the lateral palmar digital nerve with 1 ml air and local anaesthetic to simulate gas accidentally introduced during regional anaesthesia. Half the horses underwent limited exercise after which all horses were radiographed at 15 and 45 min and then every 24 h until all evidence of gas had disappeared. Intra-articular gas appeared as gas capped radiolucencies (GCR) in the proximal aspect of the joint. Extra-articular gas appeared as linear radiolucencies (LR) which initially tended to migrate proximally. There was no significant difference in gas resorption in exercised and nonexercised horses. All gas was resorbed within 96 h with most of the gas already gone at 48 h.

Frequency of radiographic procedures in an urban 62-year-old population in relation to general health, body build, bone mineral content, locomotor discomfort, occupational work load and socio-economic factors

For 830 62-year-old residents of the city of Malmö records of radiographic examinations made over a period of 40 years at the Radiological Department of Malmö General Hospital and/or over 20-30 years at two private radiological departments in the city were reviewed. Radiographic examination had been undertaken in 92% of the residents, with on an average 16 examinations per resident. The most common examinations were of the chest in 63% of the residents followed by lower limb (58%) and spine (52%) examinations. In men the total number of radiographic examinations were negatively correlated to income, intelligence test results and social network and job satisfaction. Men with monotonous work and a more restricted latitude for decision-making at work, as well as men who were smokers had also had significantly more radiographic examinations. Single civil status and occupational work load had in men a positive correlation with the total number of radiographic examinations, as well as with serum levels of glutamyltransferase and uric acid levels. In women there was a negative correlation between radiographic examinations and teachers' rating of intelligence in childhood and bone mineral content, whereas job satisfaction, life success and triceps skinfold index (= subcutaneous fat tissue thickness) had a positive correlation with the total number of radiographic examinations. Women who took regular exercise (every week) had had significantly fewer radiographic examinations. Men and women with locomotor discomfort had a significantly higher consumption of not only musculoskeletal radiographic examinations but also other radiographic examinations.

Langer mesomelic dwarfism: ultrasonographic diagnosis of two cases in early mid-trimester

This is a report on two cases of mesomelic dysplasia Langer type. This is a rare kind of dwarfism which combines severe dwarfism with predominant shortening of the forearms and lower legs and other morphological abnormalities. The diagnosis can be made by ultrasonography in the early second trimester of the pregnancy.

[Bird headed dwarfism in Seckel syndrome. Nosologic difficulties]

Seckel syndrome is a clinical picture which associates four main features: intrauterine growth retardation, microcephaly often due to craniosynostosis, orofacial dysmorphology with bird headed appearance and variable mental retardation which is present after several months. Malformations of the central nervous system, limbs, and hair, may also be observed. On the basis of 78 cases reported in the literature, the authors discuss the validity of the morphological features of the syndrome. It is likely that the variability in the expressivity of each symptom explains its heterogeneity. According to the radiological abnormalities, three different forms of the syndrome have been described. Seckel syndrome is a genetic disorder with autosomal recessive inheritance. Its ethiopatogeny remains unclear. Hopefully linkage studies will allow to map the gene in order to determine the underlying abnormal protein.

[Value of computed tomography in the diagnosis of fistulas]

PURPOSE

The purpose of the study was to determine the value of computed tomography (CT) in demonstrating fistulae in comparison with conventional radiographic methods.

METHODS

In a prospective study 25 patients were evaluated by conventional radiographic methods and CT.

RESULTS

The identification of the fistulous tract was possible with CT in 27 of 29 cases, whereas 2 fistulae could only be detected by indirect signs. Furthermore, CT showed a larger extent of the fistulous tract in 5 patients and revealed complications such as inflammatory mass, abscess or osteomyelitis in 11 cases.

CONCLUSION

CT seems to be superior in demonstrating the extent of a fistulous tract and provides valuable information on the surrounding structures.

Added value of radiologist consultation to family practitioners in the outpatient setting

PURPOSE

To measure the added value of a radiologist's consultation to the interpretation of radiographs previously read by a family practitioner.

MATERIALS AND METHODS

The authors reviewed 1,674 chest and extremity radiographs previously read by a family practitioner and consulting radiologist. The 196 radiographs in which there was a discrepancy between the family practitioner's and radiologist's report were evaluated by a radiologist and family physician not involved in and blinded to the original interpretations. The overall accuracy of the participants was determined and differences statistically quantified.

RESULTS

The overall sensitivity of the radiologists was greater than that of the family practitioners (92% vs 86%); specificity was not significantly different. For extremity examinations, there were no significant differences in accuracy of the radiologists and family practitioners; the sensitivity of radiologists for chest studies was considerably greater (89% vs 80%). Radiologic consultation was of particular value in the detection of pneumonia and masses.

CONCLUSION

At a family practice center, the radiologist's role for extremity radiographs might be limited to individual consultation, with review of all chest radiographs.

Geleophysic dysplasia: a report of three affected boys--prenatal ultrasound does not detect recurrence

Geleophysic dysplasia is characterized by short stature with short limbs and brachydactyly, a "happy" facial appearance, and joint contractures. Infiltration of heart valves and liver with a mucopolysaccharide-like substance has been demonstrated in some patients. A metabolic pathogenesis is suspected, but has not yet been identified. We report on 3 boys with the condition, 2 of whom are brothers. Serial ultrasound scans were performed on 2 of the cases during pregnancy, but short limbs did not become obvious until after 28 weeks of gestation, making it an uninformative procedure for prenatal diagnosis.

[Effects of copper needling therapy on cavernous hemangioma assessed by echogram]

Thirty-one patients with subcutaneous cavernous hemangioma were observed by echogram before and after treatment with copper needling. Different characteristics of echogram were found in hemangioma before and after treatment. Color Doppler imaging gave great help in the diagnosis and treatment of this disease and follow-up.