Additional Radiographic Studies Research Articles

SC16.03 Radiotherapy for Sulcus Superior Tumors

SC16.03 Radiotherapy for Sulcus Superior Tumors

COL1A1 and COL1A2 sequencing results in cohort of patients undergoing evaluation for potential child abuse.

Child abuse is a major public health concern that can explain a proportion of fractures in children. Osteogenesis imperfecta (OI) is the most common inherited syndrome that predisposes to skeletal fractures. We conducted a retrospective analysis of data from clinical, laboratory, and radiographic information from children evaluated for child abuse in which molecular testing for COL1A1 and COL1A2 genes was conducted. A total of 43 patients underwent molecular testing for OI. Pathogenic variants predicted to result in a mild form of OI were found in two patients (5%), both clinically suspected to have this diagnosis. None of the cases in whom OI molecular testing was ordered when maltreatment concerns were thought to be more likely (0/35) were identified to have pathogenic variants. After reviewing each individual case, the final diagnosis was child abuse for 34 cases (77%), and additional radiographic and laboratory studies did not identify any with inherited metabolic predisposition to fracture or rickets. We conclude that routine testing for OI in the setting of child abuse when no other suggestive clinical findings are present has a low yield. A careful review of the medical history and a detailed clinical evaluation help identify those at risk for genetic alterations. © 2016 Wiley Periodicals, Inc.

Orbital, Mediastinal, and Cervicofacial Subcutaneous Emphysema after Endodontic Retreatment of a Mandibular Premolar: A Case Report

IntroductionSubcutaneous emphysema (SCE) rarely occurs from endodontic treatment. Most reported cases of iatrogenic SCE occur in the cervicofacial region. Only a few cases have been reported of SCE extending into the mediastinum or orbital spaces. In the present report, we describe a concomitant occurrence of orbital, mediastinal, and cervicofacial SCE immediately after endodontic retreatment. MethodsA 33-year-old woman presented to the hospital with acute swelling of the right side of her face and neck. Earlier in the day, she began experiencing rapid swelling while undergoing endodontic retreatment of a mandibular right first premolar by her general dentist. The dentist immediately referred the case to an oral surgeon who then ordered additional tests and radiographic studies at the hospital. From there, the patient received consultation and comprehensive treatment by a multidisciplinary team of medical and dental staff. ResultsPhysical examination, laboratory tests, and computed tomographic studies confirmed a diagnosis of SCE. Extensive air pockets were detected within the orbital, mediastinum, and cervicofacial spaces. The patient was admitted to the hospital and underwent treatment and observation for massive SCE with likely secondary infection. On the fifth day, she was discharged after showing dramatic improvement. ConclusionsSCE may go undetected or misdiagnosed. Complications may be fatal. Therefore, clinicians should apply preventive measures and know how to identify and manage SCE. We review reports of SCE in the last century, discuss etiology and differential diagnosis, and present recommendations for prevention and management of SCE.

Economic Impact of Additional Radiographic Studies After Registered Diagnostic Medical Sonographer (RDMS)-Certified Emergency Physician-Performed Identification of Cholecystitis by Ultrasound

The standard evaluation of patients with right upper quadrant (RUQ) abdominal pain consists of a history and physical examination, laboratory analysis, and radiological investigation. Given the increasing availability of bedside ultrasound in the Emergency Department (ED), a growing proportion of Emergency Physicians are now performing their own ultrasound examinations in patients with RUQ abdominal pain to circumvent diagnostic delays and improve patient care. To determine the economic "opportunity" costs of additional radiographic testing after identification of acute cholecystitis by focused ED ultrasound performed by registered diagnostic medical sonographer (RDMS)-certified personnel. A retrospective analysis of a consecutive sample of patients with "positive" focused ED ultrasounds of the RUQ that were significant for cholecystitis, who presented from June 1, 2005 through February 30, 2006. Cost analysis was performed using standard Medicare compensation indices for radiological examinations of the abdomen/hepatobiliary system. There were 37 patients enrolled; 32 patients exhibited RUQ pain with a focused ED ultrasound significant for cholecystitis. Eight (25%) patients received no further radiographic tests and exhibited positive pathology. Twenty-four (75%) patients had additional diagnostic examinations; 22 (92%) showed positive pathology. Based upon Medicare compensation indices, an opportunity cost of $6885.34 was incurred at our institution over 9 months due to additional examinations. Using nationally comparable indices, this was extrapolated to an opportunity cost of $63 million (95% confidence interval $48.3-$78.9 million) per year across the nation, assuming that 50% of patients with cholecystitis present to the ED and receive an ultrasound examination by an RDMS-certified Emergency Physician. In this small sample, additional radiological testing after ED ultrasounds significant for acute cholecystitis led to sizable economic costs on a local and national level. Formal cost-benefit analyses are needed to evaluate the full economic and patient care implications of ED ultrasound use in this setting.

Usefulness of Double-Balloon Enteroscopy As a Diagnostic and Therapeutic Tool in Crohn's Disease

Background/Aims: The use of double-balloon enteroscopy (DBE) has advanced the diagnosis and treatment of small intestinal diseases. It is very important to evaluate the small intestinal lesions in Crohn's disease. The aim of this study was to evaluate the usefulness of DBE in the examination of the small intestine in patients with Crohn's disease. Methods: Sixty DBE examinations by the anal route were performed in 41 patients with Crohn's disease from 2003 to 2007 in our hospital. In cases where abnormal findings were observed, after inserting the end of DBE, the balloon attached to the tip of DBE was inflated, and radiographic contrast study by injection of liquid contrast medium through the channel of DBE was also performed. Results: Fifty abnormal findings, including longitudinal ulcer, erosion, cobblestone appearance, and inflammatory polyps were observed in 60 DBE examinations. Twenty-two active ulcers in the ileum were found in 36 patients with symptoms (60.1%), whereas 11 active ulcers were observed in 24 patients even in remission (45%). Additional radiographic contrast studies were performed in 50 patients who had abnormal findings. Twenty-six additional mucosal findings in the ileum beyond where DBE reached were obtained by radiographic contrast study (52.0%). These findings included longitudinal ulcer, stricture and internal fistula. DBE examinations were performed in 9 CD patients at 6 months after the resection of small intestine. Seven patients were treated with azathioprine and all patients were in clinical remission. Active ulcers were observed in three patients (33.3%) whom we started to treat with infliximab. Conclusion: DBE is useful in the evaluation of small intestinal lesions with Crohn's disease. We suggest that it is necessary to make periodic evaluations of mucosal lesions in the small intestine by DBE because active ulcers are found even in patients in the remission phase. The combination of DBE and radiographic contrast study enable the examination of a wider range of the ileum, and the identification of more critical findings, such as internal fistula and stricture, than DBE by itself. These findings were the decisive factor in determining treatments.

DETECTION OF PEDIATRIC CERVICAL SPINE INJURY

In evaluating the pediatric cervical spine for injury, the use of adult protocols without sufficient sensitivity to pediatric injury patterns may lead to excessive radiation doses. Data on injury location and means of detection can inform pediatric-specific guideline development. We retrospectively identified pediatric patients with codes from the International Classification of Diseases, 9th Revision, for cervical spine injury treated between 1980 and 2000. Collected data included physical findings, radiographic means of detection, and location of injury. Sensitivity of plain x-rays and diagnostic yield from additional radiographic studies were calculated. Of 239 patients, 190 had true injuries and adequate medical records; of these, 187 had adequate radiology records. Patients without radiographic abnormality were excluded. In 34 children younger than 8 years, National Emergency X-Radiography Utilization Study criteria missed two injuries (sensitivity, 94%), with 76% of injuries occurring from occiput-C2. In 158 children older than 8 years, National Emergency X-Radiography Utilization Study criteria identified all injured patients (sensitivity, 100%), with 25% of injuries occurring from occiput-C2. For children younger than 8 years, plain-film sensitivity was 75% and combination plain-film/occiput-C3 computed tomographic scan had a sensitivity of 94%, whereas combination plain-film and flexion-extension views had 81% sensitivity. In patients older than 8 years, the sensitivities were 93%, 97%, and 94%, respectively. Younger children tend to have more rostral (occiput-C2) injuries compared with older children. The National Emergency X-Radiography Utilization Study protocol may have lower sensitivity in young children than in adults. Limited computed tomography from occiput-C3 may increase diagnostic yield appreciably in young children compared with flexion-extension views. Further prospective studies, especially of young children, are needed to develop reliable pediatric protocols.

Adjuvant intensity modulated pelvic radiation therapy in gynecologic malignancies: Survey of the gynecologic IMRT working group

Intensity modulated radiation therapy (IMRT) is receiving increasing attention in gynecologic malignancies. Dosimetric studies have demonstrated that IMRT reduces the volume of normal tissues irradiated compared to conventional techniques. Moreover, recent outcome studies have suggested that IMRT is associated with less acute and chronic toxicity. A concern, however, is that no standards exist on how gynecologic IMRT should be performed. To develop guidelines, the Gynecologic IMRT Working Group was formed comprised of investigators from the United States, Canada, Asia and Europe. Recently, members were sent a survey on intensity modulated pelvic RT (IM-PRT). The 45-question survey focused on the use of adjuvant IM-PRT in endometrial and cervical cancer. It did not address IMRT in women with an intact uterus or more comprehensive fields. The survey consisted of 6 sections: patient selection, equipment, simulation, target delineation, planning and delivery. Members were asked to give their recommendations. Twenty-seven members (18 USA, 4 Europe, 3 Asia, 2 Canada) completed the survey. Number of sections completed varied by gynecologic IMRT experience. All respondents were academic physicians (median years in practice, 13). Most (89%) were IMRT-users; 63% had treated a gynecology patient with IMRT. Most common contraindications to gynecologic IMRT cited were obesity and poor cooperation. Most respondents (78%) recommended inverse planning. All commercial planning systems were considered acceptable. Recommended positioning was supine (46%), prone (15%) or either (39%). Most (81%) recommended customized immobilization. All recommended thin (3–5 mm) planning CT slices and 88% recommended contrast at simulation, primarily intravenous, rectal, and oral contrast. Most (80%) recommended a vaginal marker. All respondents recommended contouring of the bladder, rectum, and small bowel as avoidance structures. Other tissues contoured included the femoral heads (84%), bone marrow (38%), sigmoid (4%), vulva (2%), and sacrum (2%). Most respondents (72%) recommended inclusion of the vagina, parametria, presacral region, and external, internal, and common iliac lymph nodes in the clinical target volume (CTV). Fifty-two percent, however, recommended different CTVs for cervical and endometrial cancer, the main difference being the exclusion of the presacral region in endometrial cancer. Sixteen percent did not recommend inclusion of the common iliacs in either disease. Additional radiographic studies (predominantly PET and MR) were recommended by 46% to aid in CTV delineation. All recommended a CTV-to-PTV expansion, primarily 5–10 mm. Eighteen percent recommended expansion of the normal tissues. Recommended beam configurations were: 5–9 beams (94%), equally-spaced angles (70%) and coplanar beams (88%). Sixteen respondents provided detailed input planning parameters and acceptance criteria for both PTV and normal tissue dose-volume histograms. Minimum and maximum PTV doses of 95% and 105–110% of the prescription dose were recommended by 62% and 71%, respectively. All recommended quality assurance prior to and throughout treatment. This is the first survey of the application of IMRT to gynecologic tumors and provides insight into its use at a wide variety of centers. While differences in recommended practice were observed, considerable agreement exists between investigators. These results will form the basis of an upcoming consensus statement on adjuvant IM-PRT from the Gynecologic IMRT Working Group. Current work is focused on developing guidelines for target delineation

Modeling of the naked facet sign in the lumbar spine.

The study design is a computer visualization model that simulated flexion deformities about the lumbar spine for evaluation of the naked facet sign (NFS). The objectives were to ascertain the angles of rotation required for NFS to occur in the lumbar spine with various centers of rotation about the vertebral body and to assess whether NFS correlates with unstable flexion-distraction injuries in the lumbar spine. The presence of the NFS on axial computed tomography (CT) images occurs when the inferior articulating facet of the cephalad vertebra is not paired with an adjacent superior articulating facet of the caudal vertebra. This sign, when evidenced in the lumbar spine, is suggestive of significant injury secondary to a flexion-distraction force. A previous study using a computer-generated spine model challenged the utility of the NFS in the thoracolumbar spine. The NFS may prove to be more diagnostic of an unstable injury in the lumbar spine because of its normal lordotic resting position. A commercial spine computer visualization model was used to simulate various degrees of flexion injury in the lumbar spine. Lumbar functional spinal units (FSU) L2-L5 were each examined separately. The model simulated two CT scan slices (each 2 mm thick), which were created parallel to the inferior endplate of the cephalad vertebra of each FSU. The cephalad vertebra was rotated in 0.5 degrees increments until NFS was produced. The appearance of NFS required >/=11 degrees kyphotic angulation in more than two thirds of simulated centers of rotation about the lumbar vertebral bodies. The NFS was produced between a range of 8-24.5 degrees. For rotations about a point located 3 cm anterior to the vertebral body (to simulate seat-belt-type flexion-distraction injuries), the minimum angle required for NFS was 7.5 degrees. Our data correlate well with previously published results from in vitro and cadaveric studies. As opposed to the thoracolumbar spine, which normally rests in a neutral position, the lumbar spine normally rests in a lordotic position. Therefore, NFS in the lumbar spine may be more suggestive of an unstable injury and would warrant closer examination of the patient and additional radiographic studies.

Prospective Comparison of Computerized Tomography and Excretory Urography in the Initial Evaluation of Asymptomatic Microhematuria

The ideal imaging study for evaluation of the upper urinary tract in patients with microhematuria has been debated. We prospectively compared the diagnostic yield of computerized tomography (CT) to excretory urography (IVP) in the initial evaluation of asymptomatic microhematuria. Between December 1998 and June 2001, 115 patients presenting with asymptomatic microhematuria underwent CT and IVP before cystoscopy. Helical CT images with 5 mm. adrenal and kidney slices with and without contrast material were followed by delayed 5 mm. ureteral contrast images through the bladder base. Each CT and IVP was examined by a radiologist who was blinded to the result of the other imaging study. Diagnostic yields of the imaging techniques were compared using the test of 2 proportions and chi-square analysis. Radiographic abnormalities were noted on CT or IVP in 38 patients. Sensitivity was 100% for CT and 60.5% for IVP, and specificity 97.4% for CT and 90.9% for IVP. CT accuracy was 98.3% compared to IVP accuracy which was 80.9% (p <0.001). A total of 40 nonurological diagnoses were made by CT, including 3 abdominal aortic aneurysms and 1 iliac artery aneurysm. No additional diagnoses were made by IVP. Fewer additional radiographic studies were recommended after CT than after IVP. The use of CT in the initial evaluation of asymptomatic microhematuria results in better diagnostic yield. In addition, more nonurological diagnoses can be made and less additional radiography is needed to confirm a diagnosis.

Use Of Titanium Staples During Upper Tract Laparoscopic Reconstructive Surgery: Initial Experience

Using nonabsorbable titanium staples in the lower urinary tract during laparoscopic nephroureterectomy has been shown to be safe. Laboratory studies of titanium staples in the upper urinary tract have likewise been favorable. Therefore, we used titanium Endo-GIA tissue staples (United States Surgical, Norwalk, Connecticut) to facilitate laparoscopic reduction pelvioplasty during laparoscopic pyeloplasty. Of the 17 cases of reduction pelvioplasty closure was done in 12 using absorbable sutures, while in 5 reduction was done with an Endo-GIA stapler. Followup consisted of office visits and telephone interviews plus radionuclide renal scans. Average operative time was 5.5 hours in the Endo-GIA group compared with 6.8 hours in the sutured group. In the latter group extravasation in 2 patients postoperatively was managed conservatively. There was no extravasation in the stapled group. At a median subjective followup of 27 months none of the 5 patients who underwent reduction with titanium staples had symptomatic nephrolithiasis, although new onset urolithiasis developed in 1 in the sutured group. All patients had a greater than 50% decrease in pain. Renal scans at a median of 9 months showed that all ureteropelvic junction repairs were unobstructed. Additional radiographic studies in 2 patients in the stapled group showed a patent ureteropelvic junction and no stones. Titanium staples provide rapid, secure closure of the renal pelvis during laparoscopic pyeloplasty. While the risk of stone formation is an ongoing concern, it has yet to materialize.

“medical clearance” of psychiatric patients without medical complaints in the Emergency Department

This study was conducted to evaluate the benefit of comprehensive “medical clearance” (history, physical examination, vital signs, laboratory, radiography) in patients presenting to the Emergency Department (ED) with isolated psychiatric complaints. All patients 16 years and older who presented with a psychiatric complaint and required a psychiatric evaluation before discharge from the ED were included in the study. Data, obtained in a 5-month consecutive, retrospective chart review, included patient age, sex, initial complaint, past medical and psychiatric history, initial vital sign measurement, physical examination findings, laboratory analysis (electrolytes, complete blood count, toxicology screen), chest X-ray study results, and final disposition. The number of patients who could have been referred to a psychiatric unit after a history, physical examination, and stable vital signs, without additional laboratory or radiographic studies, was determined. There were 212 patients who met the inclusion criteria, and all their charts were available for review. Eighty patients (38%) presented with isolated psychiatric complaints coupled with a documented past psychiatric history. All received a comprehensive “medical clearance” in the ED followed by a psychiatric consultation. None of the patients had positive screening laboratory or radiographic results. All were either dispositioned home or to the psychiatric ED. The remaining 132 patients (62%) presented to the ED with medically based chief complaints or past medical history requiring further evaluation in the ED before discharge. The initial complaints of these patients correlated directly with the need for laboratory and radiographic “medical clearance” in the ED. Patients with a primary psychiatric complaint coupled with a documented past psychiatric history, negative physical findings, and stable vital signs who deny current medical problems may be referred to psychiatric services without the use of ancillary testing in the ED.

Vascular malformations of the upper limb: a review of 270 patients.

Vascular malformations of the upper limb were once thought to be impossible to properly diagnose and treat. We reviewed our experience with these malformations of the upper limb in 270 patients seen over a 28-year period. These anomalies were slightly more common in females than males (ratio, 1.5:1.0). The malformations were categorized as either slow flow (venous, n = 125; lymphatic, n = 47; capillary, n = 32; combined, n = 33) or fast flow (arterial, n = 33). Three categories of fast-flow malformations were identified and designated as types A, B, and C. Over 90% of these lesions could be properly diagnosed by their appearance and growth pattern within the first 2 years of life. Additional radiographic studies were used to confirm this diagnosis and to define specific characteristics. Magnetic resonance imaging with and without contrast best demonstrated site, size, flow characteristics, and involvement of contiguous structures for all types of malformations. Algorithms for treatment of both slow-flow and fast-flow anomalies are presented. Two hundred sixty surgical resections were performed in 141 patients, including 24 of 33 fast-flow anomalies. Preoperative angiographic assessment, with magnified views, was an important preoperative adjunct before any well-planned resection of fast-flow arteriovenous malformations. The surgical strategy in all groups was to thoroughly extirpate the malformation, with preservation of nerves, tendons, joints, and uninvolved muscle, and microvascular revascularization and skin replacement as required. Resections were always restricted to well-defined regions and often completed in stages. Symptomatic slow-flow malformations and types A and B fast-flow anomalies were resected without major sequelae. Type C arterial anomalies, diffuse, pulsating lesions with distal vascular steal, and involvement of all tissues, including bone, progressed clinically and resulted in amputation in 10 of 14 patients. The complication rate was 22% for slow-flow lesions and 28% for fast-flow lesions.

Evaluation of hand and wrist injuriesin athletes

Injuries to the wrist and hand are very common in athletes. Timely treatment is very important because these injuries result in short- and/or long-term disability. A correct diagnosis allows treatment, which often requires immobilization, rest, and/or time away from sport, to begin immediately. The key to an accurate diagnosis is a thorough patient history and physical examination. Specific physical signs and appropriate use of additional radiographic and special imaging studies are often used to confirm the diagnosis.

Craniocervical junction subarachnoid hemorrhage associated with atlanto-occipital dislocation.

The sensitivity of plain radiographs for diagnosing traumatic atlanto-occipital dislocation and its association with craniocervical junction subarachnoid hemorrhage was examined in a retrospective review of seven patients. The purpose of this study was to demonstrate the frequency of nondiagnostic plain radiographs and the common association of craniocervical junction subarachnoid hemorrhage in the context of reported cases of atlanto-occipital dislocation to facilitate better recognition of this injury. The use of sagittal reconstructions of computed tomography or sagittal magnetic resonance imaging for diagnosis was evaluated. Although traumatic atlanto-occipital dislocation is a common cause of motor vehicle fatalities, survival has been more common in the last 16 years. However, the diagnosis was missed on lateral cervical radiographs in 38% of children and 59% of adults; fewer than half were diagnosed subsequently with plain radiography. Moreover, the diagnosis of traumatic atlanto-occipital dislocation often was not considered, because more than half of the survivors had no neurologic abnormality or unilateral deficit. Consequently, more than one third of initially undiagnosed patients experienced neurologic deterioration due to inadequate cervical immobilization. Additional radiographic studies allowing diagnosis were prompted by the neurologic worsening. The authors reviewed seven patients treated with traumatic atlanto-occipital dislocation during a 14-year period. Emergency department records were compared with reexamination of initial cervical radiographs to determine the success in diagnosis by means of published methods. The frequency of cranio-cervical junction subarachnoid hemorrhage on computed tomography was determined, and the use of sagittal imaging for subsequent diagnosis was evaluated. In the emergency department, only one patient's condition was diagnosed as atlanto-occipital dislocation. Review of the initial radiographs identified an additional four patients for whom atlanto-occipital dislocation could be diagnosed. Sagittal computed tomography reconstruction or sagittal magnetic resonance imaging identified the remaining two. All but one patient had craniocervical junction subarachnoid hemorrhage. A review of reported cases revealed a common association of craniocervical junction subarachnoid hemorrhage with traumatic atlanto-occipital dislocation but not with traumatic head injury. The diagnosis of traumatic atlanto-occipital dislocation is often missed in the emergency department, and current methods for evaluating the integrity of the atlanto-occipital joint on cervical radiographs fail to identify all patients with this injury. Although infratentorial subarachnoid hemorrhage is uncommon in traumatic head injury, craniocervical junction subarachnoid hemorrhage is often associated with atlanto-occipital dislocation and should raise the suspicion of severe craniocervical ligamentous injury. Sagittal computed tomography reconstructions or sagittal magnetic resonance imaging can allow for the diagnosis when plain radiography is inconclusive.

Serum prostate-specific antigen as a predictor of radiographic staging studies in newly diagnosed prostate cancer.

The standard staging evaluation of prostate cancer includes digital rectal examination, measurement of serum tumor markers, radionuclide bone scan, and abdominal pelvic computed tomography (CT) or nuclear magnetic resonance imaging (MRI). We retrospectively reviewed 300 cases of newly diagnosed, untreated adenocarcinoma of the prostate to evaluate the ability of serum prostate-specific antigen (PSA) to predict results of staging radiographic studies (bone scan, CT/MRI). The medical records of 300 newly diagnosed, untreated prostate cancer patients were reviewed. The following information was collected on a standard data form: age, clinical stage based on digital rectal examination, method of diagnosis, histological grade, serum PSA level, results of radionuclide bone scan and additional radiographic studies to confirm bone scan results, results of abdominal pelvic CT/MRI, and presence or absence of bone pain. The results of this review were tabulated and analyzed with regard to the ability of serum PSA level to predict positive results of radiographic staging studies. The mean PSA level of the study group was 24.6 ng/ml. Ten patients (3.6%) presented with positive bone scan results with 5 of these having serum PSA levels greater than 20 ng/ml (range 27.6 ng/ml-144 ng/ml, mean 66.3 ng/ml). The 5 remaining patients all had elevated PSA levels ranging between 4.1 and 20.0 ng/ml. No patient with a positive staging bone scan presented with a normal serum PSA. Ten patients (4.0%) presented with a positive abdominal/pelvic CT/MRI (adenopathy only; no patients had radiographic evidence of abnormalities of the upper urinary tract). Eight had serum PSA levels greater than 20 ng/ml, ranging from 30.0 to 234 ng/ml. No patient with a positive study presented with a normal serum PSA level. No patient with either positive bone scan or abdominal pelvic CT/MRI presented with bone pain. We conclude that in asymptomatic patients with newly diagnosed, untreated prostate cancer and serum PSA levels of less than 10 ng/ml, a staging radionuclide bone scan may not be necessary. Likewise, in patients with serum PSA levels of less than 20 ng/ml the likelihood of positive findings on abdominal/pelvic CT/MRI is extremely low. Abdominal/pelvic CT/MRI does not appear necessary in this setting. With over 130,000 cases of newly diagnosed prostate cancer each year in the United States, elimination of staging radiographic studies in the patients outlined above could result in economic savings on the order of 30-80 million dollars per year.

Radiographic evaluation of cervical spine injuries.

This study involves an evaluation of specific radiologic patterns of various cervical spine injuries on plain radiographs in order to determine a rational approach for further radiologic investigation and resultant treatment. We retrospectively reviewed 236 patients with 319 cervical spine injuries. Fractures included 50 of the dens, 21 hangman, 4 Jefferson, 29 burst, 24 compression, 32 corner/teardrop, 65 facet, 24 lamina, and nine pedicle. Dislocations included one occipitoatlantal, two atlantoaxial rotatory, and 28 facet. Pleuridirectional tomography performed in 137 cases and computerized tomography was performed in 26. The cases were divided into three groups according to the significance of their radiographic findings: Group I: no additional information was added by the additional radiographic studies compared to the plain radiographs. Group II: the additional radiographic studies changed the extent or type of injuries seen on the plain radiographs. Group III: plain radiographs were negative. The abnormalities were only found on the additional radiographic studies. Results of 137 patients undergoing tomography: 62 were in group I, 64 were in group II, and 11 were in group III. Of the 26 patients undergoing computerized tomography, 13 were in group I, 13 were in group II, and no patients were in group III. Specific fracture types were reviewed according to the distribution of the three groups. We concluded that pleuridirectional tomography appears to be particularly advantageous in patients with injuries involving the facets. Computerized tomography appears to add the most additional information in patients with laminar and posterior element fractures and C1 fractures. We feel that timely and accurate diagnosis of cervical spine injuries is essential.(ABSTRACT TRUNCATED AT 250 WORDS)

Fracture of the dorsoulnar tubercle of the trapezium

The dorsoulnar tubercle of the trapezium may fracture, and this fracture may be missed without precise physical examination and correct radiographic studies. If there is persistent localized pain and tenderness in this region and the results of routine wrist radiographic examination are normal, a bone scan should be performed. If there is localized uptake in the area of the trapezium, additional radiographic studies may be necessary to confirm or exclude this fracture. Four patients with this previously unreported fracture and a method for its detection are presented.

Myositis Ossificans

Although most physicians associated myositis ossificans with recent, acute trauma, only 40%-60% of patients give such a history. The appearance of a soft tissue mass without a clear history of trauma may suggest a diagnosis of sarcoma, especially because results of a biopsy of the central portion of an area of myositis ossificans may yield immature, undifferentiated tissue resembling a sarcoma. Pain and rapid growth of a mass are more usual in myositis ossificans than in sarcomas, and careful inquiry may reveal stretching injury or chronic trauma associated with normal, vigorous, physical activities. Recognizing the characteristic histologic zoning phenomenon (immature tissue centrally surrounded by more mature tissue and a peripheral shell of benign bone) during the biopsy procedure permits the correct diagnosis of myositis ossificans. Plain radiographs or conventional tomograms may reflect this histologic zoning by demonstrating the typical, mature, outer shell of bone. Although additional radiographic studies are not usually necessary, they may be obtained when the mass is suspected to be a sarcoma. In two patients computed tomographic scans clearly demonstrated well-defined, peripheral shells of mature bone, diagnostic of myositis ossificans.

Non-focal enlargement in pancreatic carcinoma.

Pancreatic adenocarcinoma can appear radiographically as enlargement of the major part of the pancreas. In this series, part or all of three or more pancreatic segments (head, neck, body, and tail) were involved in 27% of patients with adenocarcinoma who had computed tomography. Differentiation from pure pancreatitis may require additional radiographic studies. The varied tissue composition of a pancreas enlarged by adenocarcinoma will often require biopsy of multiple sites for confirmation.

Comparison Radiographs of Extremities in Childhood: Recommended Usage

Extremity injuries, a common problem in pediatric practice, are responsible for a significant number of radiographic examinations performed on children each year. Radiologic diagnosis in these injuries may be complicated by the variable appearance of the growing skeleton, especially around the epiphyses and the physeal plate. In the past, it has been a common and accepted practice for pediatricians, generalists, orthopedic surgeons, and radiologists to obtain routinely radiographs of the uninjured limb1-3 for comparison with those of the injured extremity to rule out subtle fractures or dislocations. Recently, increasing concern about potential dangers of ionizing radiation, coupled with agitation from insurance carriers and governmental agencies to reduce escalating medical costs, has resulted in mounting pressure to limit diagnostic radiographic examinations. At the same time, however, rising malpractice litigation has, in many instances, forced physicians to obtain additional radiographic studies to "protect" themselves, especially in trauma cases. Radiographs of traumatized extremities contribute significant numbers of medicolegally oriented radiologic examinations each year. Although comparison views are no doubt helpful in some instances, until recently there has not been any effort to document the extent of use or diagnostic value of comparison views, especially those routinely obtained. Within the past two years there have been two studies on this problem. In 1977, a survey4 of pediatric radiologists throughout the United States and Canada sought to determine individual application of comparison views, whether selective or routine; factors that influence this use; extent of comparison views, whether single or multiple; and cost of the additional radiographic studies.