Sonography of the patellar tendon and adjacent structures in pediatric and adult patients

Strain Elastography Evaluation of Patellar Tendons in Dogs after TPLO/TTA for Cranial Cruciate Ligament Rupture, Qualitative and Semiquantitative Evaluation Compared with Healthy Subjects

Strain elastography (SE) evaluates tissue stiffness, providing qualitative and semiquantitative evaluation, with a strain ratio (SR) > 1 indicating that the target lesion is stiffer than the reference tissue. The patellar tendon has been described as soft in healthy dogs and hard in dogs with cranial cruciate ligament rupture, but SR usefulness has not been assessed. Dogs were divided into healthy (G1) and at least 1 month after surgery (G2) groups. Thickness was recorded, and a B-mode score of 0-3 was determined based on the abnormality's severity. SE was qualitatively performed with a score of 1-4, and EI was recorded on the whole ligament and in proximal, intermediate and distal areas; SR was collected with the fat pad and cutis/subcutis. G1 was significantly thinner, with a lower score than G2 and a more elastic pattern. EI for G1 was significantly lower than G2 for the whole tendon and the single portions, and EI for the distal portion was significantly lower than the proximal and intermediate one in G2. SR was <1 in G1 and >1 in G2 for both the fat pad and cutis/subcutis. These data suggest that after surgery, the tendon may become non-uniformly stiffer. The cutis/subcutis appears to be a more reliable reference tissue than the infrapatellar fat pad.

Sinding-Larsen-Johansson disease. Clinical features, imaging findings, conservative treatments and research perspectives: a scoping review

Objective

This review aims to consolidate existing research on the pathogenesis, clinical diagnosis, imaging outcomes, and conservative treatments of Sinding-Larsen-Johansson disease (SLJD), identifying literature gaps.

Design

Scoping Review.

Methods

A comprehensive literature search was conducted across databases including PubMed, Scopus, Medline OVID, Embase, Web of Science, and Grey literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) checklist.

Results

The body of evidence on SLJD, primarily derived from case studies, reveals limited and often conflicting data. Key findings include: (1) SLJD commonly presents as localized knee pain in physically active adolescents, particularly males, (2) ultrasound and MRI are the most effective diagnostic tools, (3) conservative treatment, which mainly focuses on activity limitation, yields positive outcomes within two to eight months.

Conclusions

Our review shows that SLJD mainly affects physically active adolescents aged 9-17 years. The authors recommend conservative treatment, rest and/or cryotherapy, passive mobilization, muscle restraint, isometric exercise, and NSAIDs. Further cohort studies are necessary to refine the management and application of the SLJD treatment database.

Technical and Interpretive Pitfalls in Pediatric Musculoskeletal Ultrasound

The use of musculoskeletal (MSK) ultrasound (US) in pediatric rheumatology has expanded rapidly with various diagnostic and therapeutic indications. Unlike magnetic resonance imaging (MRI), US allows real-time dynamic assessment, evaluation of multiple joints in a single session and comparison with contralateral limb. However, a long learning curve and lack of experience with MSK US in pediatric patients still precludes its routine use at many imaging centers. It is prudent for pediatric radiologists to be aware of normal US appearances of the growing MSK structures to avoid their misinterpretation as pathology. The normal MSK US findings in children which can be confused with pathology and create diagnostic difficulty can arise due to variable states of maturation of bones, cartilage and tendons, complex anatomical locations, accessory structures, and artifacts. Herein, we describe the various technical and interpretive challenges encountered with MSK US in pediatric patients.

A Tibial Tubercle Fracture Masquerading as an Inferior Pole of the Patella Fracture

Pediatric tibial tubercle fractures are uncommon injuries that most often occur in adolescent men. Patients will typically present with anterior knee pain with or without patella alta. This case report describes a tibial tubercle fracture in a 13-year-old man misidentified as an inferior pole patella sleeve fracture on physical examination and preoperative radiographs. The tubercle reduction was secured with cannulated screws while injury to the patellar tendon periosteal sleeve was repaired with suture anchors. This case highlights the utility of advanced imaging when the etiology of extensor mechanism disruption is unclear. Furthermore, it is imperative to set expectations with parents and guardians that the full extent of the injury may only be confirmed under direct visualization in the operating room because of the complexity of such injuries.

Normal and abnormal tendons in children: evaluation with ultrasound

Ultrasound (US) has emerged as an essential diagnostic tool for evaluating the entire musculoskeletal system in children. The spatial resolution of modern US technology offers unparalleled depiction of superficial anatomy, and motion and blood flow are demonstrated in real time allowing for the quick diagnosis of a wide variety of pathologies. US evaluation of tendons and their structure and function represents one of the best applications of musculoskeletal US. This article reviews some of the more common indications for US of the tendons in children. While not an exhaustive list, the anatomy and pathology examples described should help any pediatric radiologist confronted with a case of tendon pain or loss of function.

Imaging Review of Hockey-related Lower Extremity Injuries

Hockey is a fast-paced contact sport with a high incidence of injuries. Although injuries are more frequent among elite players, recreational hockey injuries are a common issue faced by primary care and emergency physicians. Lower extremity injuries in hockey are particularly important because they account for approximately a third of all injuries and > 60% of all overuse injuries. This pictorial review provides the general and specialty trained radiologist with a knowledge of the patterns of lower extremity injury that occur in ice hockey.

Evaluation of the risk of patella fracture as the result of decreasing tibial plateau angle following tibial plateau leveling osteotomy

OBJECTIVE

To evaluate the effect of postoperative tibial plateau angle (TPA) following tibial plateau leveling osteotomy (TPLO) on the risk of patella fracture during the convalescent period.

STUDY DESIGN

Retrospective study.

SAMPLE POPULATION

Fracture group: 20 stifles; reference group: 65 stifles.

METHODS

Medical records were reviewed for stifles with patellar fractures after a TPLO procedure (fracture group) and stifles with >180 days radiographic examination with no complications following TPLO (reference group). Stifle radiographs were masked to group and final TPA (fTPA) was measured, at the time of fracture diagnosis (fracture group) and at last follow-up (reference group), using PACS software. TPAs in the fracture and reference groups were compared using the Wilcoxon rank-sum test. Statistical significance was set at .05.

RESULTS

Patellar fractures were diagnosed at a median of 69 days (range 31-189) after surgery. The median duration of follow-up time for the reference group was 471 days (range 180-1868). Median fTPA for the fracture group was 1.4° (range [-10.3]-7.1). Median fTPA for the reference group was 4.1° (range [-3.9]-14.1). The odds of patellar fractures increased by 21.7% (95% CI: 8.6%-35.6%) for every 1° decrease in fTPA.

CONCLUSION

The risk of patella fractures increased as TPAs after TPLOs decreased.

CLINICAL SIGNIFICANCE

Care should be taken to avoid excessive rotation during TPLO to decrease the likelihood of postoperative patellar fractures.

Influence of methods of joint inspection during tibial plateau leveling osteotomy on the radiographic appearance of the patellar tendon

OBJECTIVE

To determine the influence of methods of joint inspection during tibial plateau leveling osteotomy (TPLO) on radiographic appearance of the patellar tendon.

STUDY DESIGN

Retrospective study.

ANIMALS

Client-owned dogs (191) treated with TPLO (199).

METHODS

Data collected from medical records included signalment, weight, duration of anesthesia and surgery, preoperative and postoperative tibial plateau angle (TPA), cranial cruciate ligament status, meniscal status, and meniscal treatment. Method of joint inspection was recorded as (1) arthroscopy (AR), (2) craniomedial parapatellar arthrotomy (CrMA), or (3) caudomedial arthrotomy (CdMA). The radiographic thickness of the patellar tendon (PTT) was measured preoperatively and at 8-12 weeks postoperatively. Radiographic signs of patellar tendonitis were graded as 0-2 on the basis of the severity of changes.

RESULTS

Thirty-nine dogs (41 stifles) underwent AR, 86 dogs (87 stifles) underwent CrMA, and 70 dogs (71 stifles) underwent CdMA. Durations of surgery (P < .001) and anesthesia (P < .001) were longer when joints were inspected by AR than by arthrotomies. PTT was greater after AR than after CrMA (P = .004) and CdMA (P < .001). The proportion of dogs with grade 1 or grade 2 PTT was greater after AR (78.04%) than after CrMA (52.87%, P = .0065) and CdMA (28.17%, P < .001).

CONCLUSION

The PTT was thicker 8-12 weeks after TPLO when stifles were inspected arthroscopically rather than via arthrotomies.

CLINICAL SIGNIFICANCE

The method of stifle exploration during TPLO influences the postoperative radiographic appearance of the patellar tendon and may contribute to patellar tendinopathy.

The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries

Musculoskeletal trauma in the paediatric population covers a wide range of injuries; although many overlap with their adult counterparts, others are exclusive to the immature skeletal system. Ultrasound is a versatile tool particularly suited to both the imaging of children and the dynamic assessment of musculoskeletal injuries. This pictorial review aims to discuss a range of injuries, focusing on those commonly encountered in children. We shall describe the muscle-tendon-bone complex and changes that occur with increasing skeletal maturity and how this affects the type of injury encountered.

Pediatric musculoskeletal injuries: role of ultrasound and magnetic resonance imaging

Pediatric musculoskeletal system is particularly prone to traumatic and sports-related injuries, both acute and chronic, i.e., overuse injuries, because of inherent conditions of weakness, such as the open physis, representing the weakest aspect within the bone, the ligamentous supports and changing biomechanics. Being aware that a quick diagnosis is essential to preserve the good functionality of the limb involved, it is mandatory for the radiologist to recognize the most common patterns of these injuries, identifying those requiring a prompt surgery, as well as be confident with the technique performed, and be supported by an important background experience and knowledge skills.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review

Osgood-Schlatter disease (OSD) is a condition in which the patellar tendon insertion on the tibial tuberosity becomes inflamed. It is a well-known condition in late childhood characterized by pain and a bony prominence over the tibial tuberosity. The pain is usually exacerbated by physical activities like running, jumping, and climbing stairs. In the acute stage, the margins of the patellar tendon become blurred in radiographs due to the soft tissue swelling. After three to four months, bone fragmentation at the tibial tuberosity is viewed. In the sub-acute stage, soft tissue swelling resolves, but the bony ossicle remains. In the chronic stage, the bone fragment may fuse with the tibial tuberosity which can appear normal.

The primary goal in the treatment of OSD is the reduction of pain and swelling over the tibial tuberosity. The patient should limit physical activities until the symptoms are resolved. In some cases, the patient should restrict physical activities for several months. The presence of pain with kneeling because of an ossicle that does not respond to conservative measures is the indication for surgery. In these cases, the removal of the ossicle, surrounding bursa, and the bony prominence is the treatment of choice.

Point-of-Care Ultrasound in the Evaluation of Pyogenic Flexor Tenosynovitis

A 4-year-old girl presented to the emergency department for evaluation of finger swelling after a dog bite. Point-of-care ultrasound was used to diagnose pyogenic flexor tenosynovitis of the digit after visualizing a fluid collection within the flexor tendon sheath. The patient underwent emergent incision and drainage of the digit with good outcome.

MRI of anterior knee pain

Anterior knee pain is the most common knee complaint. It may be due to a variety of soft tissue or osseous abnormalities. Knowledge of the radiologic appearance of the abnormalities allows more accurate diagnosis of the cause of the pain including chondral abnormalities, patellar instability and dislocation, femoral trochlear dysplasia, abnormal patellar location, bipartite patella, various tendinopathies, bursal inflammation, traction apophysitis in pediatric and adolescent patients, and miscellaneous diseases including mediopatellar plica syndrome and Hoffa's disease. Radiographs are often obtained to exclude acute osseous abnormalities, such as fractures. Magnetic resonance (MR) imaging offers superior soft tissue contrast resolution and allows for more accurate evaluation of the underlying etiology and therefore may improve treatment and possible surgical planning.

Sonography of the knee joint()

The aim of this article is to review the sonographic appearances of common disorders involving the knee joint. Ultrasound is a sensitive method for diagnosis of tendon injuries. Injured ligaments appear swollen with mixed echogenicity. Meniscal injuries and muscle tears can be easily diagnosed. Ultrasound shows synovial thickening and effusion in inflammatory arthropathy and erosions of the articular surface in degenerative arthritis. It can be used effectively in the detection of rheumatoid arthritic activity and for grading degenerative arthritis lesions. Cystic lesions, as well as benign and malignant soft-tissue masses, are clearly delineated. Ultrasound is a safe noninvasive imaging modality that can be used for diagnosis of different disorders involving the knee joint.

Patellar tendinopathy

Patellar tendinopathy is a common and serious condition in athletes. Although there have been many advances in the understanding of the histopathology, imaging, and surgical outcomes in this condition in the past decade, successful management of athletes with patellar tendinopathy remains a major challenge for both the practitioner and patient. There is a definite need for further prospective studies into etiological factors and randomized controlled trials into treatment choices.