Bony Contusions Research Articles

ROLE OF MRI IN EVALUATION OF TRAUMATIC KNEE INJURIES AMONG ADULTS; SEE YOUR KNEE BY AN EYE OF A RADIOLOGIST.

Introduction: Magnetic Resonance Imaging (MRI) as a non-invasive imaging modality plays a vital role in assessment of a wide spectrum of internal knee derangements. The objective of this study is to characterise the pattern of internal derangement of knee joint using MRI, and determines the patient management. Method: This study is a tertiary care hospital based prospective diagnostic study which was conducted in the Department of Radio diagnosis, Indira Gandhi Government Medical College and Hospital, Nagpur. This study was conducted over 90 patients who were referred from various referral centres. First Magnetic resonance imaging (MRI) knee was performed and then these patients underwent Arthroscopy. MRI images are studied for evidence of injuries to the cruciate, menisci ligaments, collateral ligaments, tendons around the knee joint, uid collections, bony contusions and soft tissue injuries. Results: Out of 90 cases 71 are males 19 are females. Left knee is commonly involved accounting for 55 cases. Right knee is involved in 15 cases. Young patients are maximum in number who suffered from knee injuries which predominantly comprises age group of 21 to 40 years. The most common complaint of patients is pain and instability. Anterior cruciate ligament (ACL) injury is the most common injury followed by Medial meniscus injury. Interpretation And Conclusion: MRI is an extremely useful imaging modality for evaluation of knee injuries. It gives valuable information to the referring orthopaedician for planning the line of treatment in terms of conservative management or surgery.it is very accurate in detecting both intra and extra articular injuries.

Assessment of functional outcome of anterior cruciate ligament reconstruction in early and delayed presentation

Introduction: Surgical techniques of anterior cruciate ligament reconstruction have evolved over the past 3 decades along with debate regarding the timing of surgery. There is no consensus in the literature regarding the optimal time of surgical intervention. Methods: A prospective comparative study was conducted on 30 patients who were diagnosed with an anterior cruciate ligament tear. Patients were equally categorised into 2 groups (15 patients) based on a presentation from time of injury as - early presentation group (3 weeks from injury). All these patients underwent reconstruction with Semitendinosus Gracilis or Peroneus longus autografts by the same surgeon where standard surgery and rehabilitation protocols were followed. Functional outcome after ligament reconstruction was assessed using the IKDC and Lysholm scores preoperatively and postoperatively at 6weeks, 3 months and 6 months. Results: The functional outcome of the knee showed better improvement in the delayed presentation group than the early presentation group in both IKDC and Tegner Lysholm scores in the initial follow-up. Both the groups also recovered with a good range of movement but the delayed group scored better than the early presentation group. But the difference was insignificant at the end of 1 year. Conclusion: The functional outcome and range of motion after reconstruction of the anterior cruciate ligament is better after the healing of the soft tissue and bony contusion.

The outcomes of quadriceps tendon autograft for anterior cruciate ligament reconstruction in adolescent athletes: a retrospective case series.

Multiple graft options exist for anterior cruciate ligament (ACL) reconstruction in an adolescent athlete. Patellar tendon harvest can lead to anterior knee pain, while hamstring tendon harvest can affect knee flexion strength and alter mechanics. Allograft is less desirable in pediatric patients due to the higher failure rate and slight risk of disease transmission. Quadriceps tendon autograft has rarely been reported for adolescent ACL reconstruction in the USA, but is an excellent option due to its large size, low donor site morbidity, and versatility. The purpose of this study is to report the outcomes of adolescents who have undergone ACL reconstruction using quadriceps tendon autograft. Twenty-two ACL reconstructions using the quadriceps autograft were performed on 21 pediatric patients by the senior author between 2010 and 2017. The patient's demographics, injury characteristics, imaging, physical examination findings, operative findings, outcomes and sports were recorded. The average age at the time of surgery was 15years. Two patients had open physes; the remainder had closing physes. 64% of patients had additional meniscal tears and 76% had bony contusions. The average duration of follow-up was 2.8years (range 2-5years). At final follow-up, there were no angular deformities or leg length discrepancies. The average quadriceps atrophy of the operative leg was 4mm. The average Lysholm score was 98. 86% of patients returned to sports. No patients had re-rupture of their operative ACL. No incidences of infections, numbness, or anterior knee pain were reported. Two patients had a second arthroscopy for re-injury, revealing new meniscal tears but intact ACL grafts. Use of quadriceps tendon autograft for ACL reconstruction in adolescent patients allows reliable return to sport with minimal complications. Level IV, retrospective case series.

Distribution of Osteochondral Lesions in Patients With Simple Elbow Dislocations Based on MRI Analysis.

Background:The clinical relationship between osteochondral lesions and long-term outcomes and patterns in the elbow joint has not yet been established. A sole evaluation from plain standard radiography may underestimate the severity of bony lesions in patients with simple dislocations. It has been suggested that the mechanism of a posterior elbow dislocation could be inferred from the pattern of bony contusions and osteochondral lesions visible on magnetic resonance imaging (MRI) in patients with simple elbow dislocations.Purpose/Hypothesis:The purpose of this study was to describe the incidence and distribution of osteochondral lesions based on MRI findings in patients with simple elbow dislocations. We hypothesized that (1) osteochondral lesions are consistently found in patients with simple elbow dislocations and (2) the distribution and severity of osteochondral lesions may explain the mechanism of the simple elbow dislocation.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective review of 43 patients with simple elbow dislocations was performed in tertiary-level hospitals from January 2010 to August 2019. Two orthopaedic surgeons separately assessed the initial plain radiographs and MRI scans. Osteochondral lesions were evaluated and categorized based on whether they were located (1) on the lateral side (posterolateral capitellum and radial head; type 1) or (2) on the medial side (posterior trochlea and anteromedial facet of the coronoid; type 2). The severity of the osteochondral lesions was assessed according to the Anderson classification.Results:Of the 43 patients, 21 (48.8%) presented with osteochondral lesions on MRI. The type 1 pattern of osteochondral lesions was the most frequently observed on MRI in patients with simple elbow dislocations (69.8% of cases), and these were confirmed by simple radiography. Posterolateral capitellum osteochondral lesions were found in 13 patients. Among them, 10 (76.9%) were advanced-stage lesions (stages III and IV according to the Anderson classification).Conclusion:Osteochondral lesions were found on MRI after simple elbow dislocations at a rate of 48.8%. Osteochondral lesions in the posterolateral capitellum were associated with an advanced stage. Clinically, these findings may help surgeons in the diagnosis of osteochondral lesions and in determining how to manage patients with the progression of arthritic changes.

Bone contusions correlate with severity and location of articular injuries after knee sprains

Introduction Bone contusions (bone marrow like edema [BMEL]), are present in 80% of anterior cruciate ligament (ACL) tears. Its clinical and pathologic meaning is still uncertain. Objectives (1) Describe the pattern of BMEL's after knee sprain; (2) correlate the severity of BMEL's with articular injuries. Methods Inclusion: age > 18 years, knee MRI with key word “sprain” in the exam prescription, and “bony contusion(s)”, “bone marrow edema”, “medullary contusion(s)” and “medullary edema” in the MRI report. Exclusion: ipsilateral knee surgery, active infectious, inflammatory or neoplastic disease. Gender and age were recorded. Evaluated data: injury to the ACL, Posterior Cruciate Ligament (PCL), Internal Collateral Ligament (ICL), External Collateral Ligament (ECL), Internal (IM) or External Meniscus (EM). BMEL's localization was divided as Internal (IFC) or External Femoral Condyle (EFC), and Internal (ITP) or External Femoral Condyle (EFC). A correlation of the geographic distribution and severity of BMEL's with intra-articular injury patterns was assessed. The statistical analysis was performed with SPSSy22.0. Results Four hundred and nine patients (207 male [M] and 202 females [F]) were included. Ninety-one (22%) presented BMEL in their MRI (54 M, 37 F), averaging 30.2 ± 7.3 years old. Eighty-eight percent presented at least one articular injury: the most frequent were menisci (59%) (IM 58%, EM 35%, IM + EM 23%) and ACL tear (54%). BMEL distribution: ICF −42%, ECF −49%, ITP −41%, ETP −44%. BMEL frequency analysis revealed one area of contusion in 48% of patients, 2 in 33%, 3 in 13% and 4 in 6% of the patients. Correlation of BMEL localization with the injured structure was statistically significant: IM-ETP in 46% (p = 0.05), EM-ETP in 59% (p = 0.029) and ITP in 56% (p = 0.026), and Central Pivot-ETP in 69% (p = 0.001). Internal areas of contusion more associated with IM injuries (p = 0.023), and external areas with LCA tears (p = 0.001). Patients with IM + EM injuries had significantly increased number of Bells (p = 0.039). Injuries to more than 2 structures correlated with increased number of BMEL's (p = 0.01). Men presented more contusions in the lateral compartment (78% vs 57%, p = 0.036) and 70% had associated menisci and ACL injuries (vs 30% in women, p = 0.032). Discussion Although gender did not affect contusion severity, men appeared to show increased severity of articular injuries. EM tears correlated with BMELs in the tibial plateau and it is interesting that EM lesion is more likely when an internal contusion is present, possibly due to the mechanism of injury. ETP contusions appear to correlate significantly with ACL tears, as described in previous studies. Deranged articular structures seem to increase with the increasing number of BMEL areas. Conclusions BMEL's appear to reflect injury mechanism and severity after knee sprains.

Defining occult injuries of the distal forearm and wrist in children.

PurposeThe nonspecific terms “wrist sprain” and “suspected occult bony injury” are frequently documented as diagnoses in occult paediatric wrist injuries. To date, however, no one has accurately defined their true underlying pathology. The primary objective of this study was to identify the true pathoanatomy of occult acute paediatric wrist injuries. Our secondary objective was to compare our findings with existing adult data in order to determine any population differences that might be clinically relevant.MethodsWe performed a single-centre retrospective case series evaluating MRI findings in acute paediatric wrist injuries presenting to the hand injury unit between 2011 and 2014. All patients underwent standardised radiographs of the wrist and, where clinically indicated, of the scaphoid. Where no bony anomaly was identified, MRI scanning was offered. Cohen’s kappa coefficient was used to calculate the agreement between clinical and MRI diagnosis.Results57 patients met the final inclusion criteria. Occult fractures and bony contusions comprised the majority of the pathologies, at 36.5 and 35.0 %, respectively. There were no cases of isolated soft-tissue injury. MRI effected management change in 35.1 % of cases. Paediatric wrists demonstrated differences in injury pattern and distribution when compared to an adult population.ConclusionThis study defines for the first time the true pathology of occult paediatric wrist injuries. The current definition of a wrist sprain was not applicable to a single case and therefore appears to be inappropriate for use in the paediatric population. A precise knowledge of the likely pathology facilitates accurate information delivery whilst reducing parental uncertainty and treatment variation.

Neurogenic Thoracic Outlet Syndrome Presenting as Chronic Elbow Pain After Obstacle Course

HISTORY: A 20-year-old female US Naval Academy freshman sustained a left elbow injury after repetitive shoulder abduction movements while completing a required obstacle course. She denied specific trauma, including a fall. There was no numbness, tingling, or radiation of pain. Five days later, she reported her left elbow pain to her physician. Originally diagnosed with an elbow contusion versus epicondylosis, the patient’s progressive left elbow pain lasted for more than 6 months when she developed ulnar dysesthesias in her hand. PHYSICAL EXAMINATION: Examination revealed diffuse elbow tenderness with swelling. Normal neurovascular examination was demonstrated. Elbow strength and range of motion were normal. Neck and shoulder exams demonstrated no abnormalities. Swelling resolved in one week. Exam remained unchanged for several months before she developed ulnar distribution pain. Then, an Allen test reproduced and worsened her elbow pain and neurologic symptoms. DIFFERENTIAL DIAGNOSIS: 1. Elbow Contusion 2. Chronic Regional Pain Syndrome 3. Intraarticular Body, Elbow Fracture 4. Brachial Plexopathy 5. Thoracic Outlet Syndrome TEST AND RESULTS: Left elbow anterior-posterior, lateral radiographs: — no acute osseous abnormality Left elbow MRI: — likely resolving bony contusion of radial head without evidence of fracture CT Left Elbow: —normal evaluation of the left elbow EMG left upper extremity: —normal electrodiagnostic study Left brachial plexus MRI: —normal left brachial plexus Chest MRI, with contrast: —findings consistent with thoracic outlet syndrome localized to costoclavicular space Left upper extremity venogram: —no evidence of venous occlusion or compression FINAL/WORKING DIAGNOSIS: Neurogenic Thoracic Outlet Syndrome TREATMENT AND OUTCOMES: 1. Relative rest, ice, compression and NSAIDs for 4 weeks without improvement. 2. Activity modification and trial of acupuncture demonstrated minimal improvement in presenting elbow pain. 3. Left scalene block with complete relief of symptoms, indicating neurogenic thoracic outlet syndrome. 4. Partial left first rib resection with resolution of chronic left elbow pain and ulnar nerve dysesthesias. 5. Range of motion, shoulder, and neck strengthening exercises started gradually 6 weeks post-surgery.

English

BACKGROUND & OBJECTIVE: Trauma to knee joint is a significant cause of morbidity in the young, active individuals and athletes. An accurate diagnosis regarding the type and extent of injuries is essential for early operative as well as non-operative treatment. The most widely used diagnostic modalities to assess the joint in jury are arthroscopy and MRI. Arthroscopy, though accurate, is invasive and can cause complications. Magnetic resonance imaging (MRI) has now been accepted as the best imaging modality for non-invasive evaluation of knee injuries. This study was undertaken to study the types and incidence of injuries in traumatic knee joint by MR imaging and to compare with arthroscopy findings in selected cases. METHODS: DESIGN: Prospective study Setting: In a tertiary care hospital, symptomatic patients who were referred from various service referral hospitals and units with history of trauma and clinical suspicion of IDK were referred to department of Orthopedics, Navodaya Medical College, Raichur. Patients: 50 consecutive patients with suspicion of IDK following knee trauma were selected for the study from 2011 to 2013. INVESTIGATIONS: Clinical examinations, MRI knee (within 4 days of referral) & in selected cases arthroscopy were performed and the findings were compared. Main Outcome Measures: Study of spectrum of MRI findings in traumatic knee and correlation of MRI findings with arthroscopy/surgical findings in selected cases. RESULTS: Of the total 50 patients evaluated, most common injury was ACL tear of which complete tears were more common. PCL tears were less common. Among the Meniscal injuries, MM tears are more common than LM and grade 2 tears are more common in both. MCL tears outnumbered LCL tears and grade 1 and 2 tears are more common in MCL. Osseous/Osteochondral lesions were seen in 17 patients (34%). Most of these were bony contusions involving the femoral and tibial condyles. INTERPRETATION AND CONCLUSIONS: From these observations, we found that MRI Magnetic resonance imaging is an excellent, non invasive, radiation free imaging modality with multiplanar capabilities and excellent soft tissue delineation. It can accurately detect, localize and characterize various internal derangements of the knee joint and help in arriving at a correct anatomical diagnosis thereby guiding further management of the patient.

Bone cysts after osteochondral allograft repair of cartilage defects in goats suggest abnormal interaction between subchondral bone and overlying synovial joint tissues

The efficacy of osteochondral allografts (OCAs) may be affected by osseous support of the articular cartilage, and thus affected by bone healing and remodeling in the OCA and surrounding host. Bone cysts, and their communication pathways, may be present in various locations after OCA insertion and reflect distinct pathogenic mechanisms. Previously, we analyzed the effect of OCA storage (FRESH, 4°C/14d, 4°C/28d, FROZEN) on cartilage quality in fifteen adult goats after 12months in vivo. The objectives of this study were to further analyze OCAs and contralateral non-operated (Non-Op) CONTROLS from the medial femoral condyle to (1) determine the effect of OCA storage on local subchondral bone (ScB) and trabecular bone (TB) structure, (2) characterize the location and structure of bone cysts and channels, and (3) assess the relationship between cartilage and bone properties. (1) Overall bone structure after OCAs was altered compared to Non-Op, with OCA samples displaying bone cysts, ScB channels, and ScB roughening. ScB BV/TV in FROZEN OCAs was lower than Non-Op and other OCAs. TB BV/TV in FRESH, 4°C/14d, and 4°C/28d OCAs did not vary compared to Non-Op, but BS/TV was lower. (2) OCAs contained “basal” cysts, localized to deeper regions, some “subchondral” cysts, localized near the bone–cartilage interface, and some ScB channels. TB surrounding basal cysts exhibited higher BV/TV than Non-Op. (3) Basal cysts occurred (a) in isolation, (b) with subchondral cysts and ScB channels, (c) with ScB channels, or (d) with subchondral cysts, ScB channels, and ScB erosion. Deterioration of cartilage gross morphology was strongly associated with abnormal μCT bone structure. Evidence of cartilage–bone communication following OCA repair may favor fluid intrusion as a mechanism for subchondral cyst formation, while bone resorption at the graft–host interface without affecting overall bone and cartilage structure may favor bony contusion mechanism for basal cyst formation. These findings suggest that cysts occurring after OCAs may result from aberrant mechanobiology due to (1) altered compartmentalization that normally separates overlying cartilage and subchondral bone, either from distinct ScB channels or more general ScB plate deterioration, and (2) bone resorption at the basal graft–host interface.

Collateral ligament injury in the displaced radial head and neck fracture: correlation with fracture morphology and management strategy to the torn ulnar collateral ligament

The purpose of our study was to correlate the morphology of displaced radial head and neck (DRHN) fractures with associated ligament injuries and evaluate the outcomes of management of the torn ulnar collateral ligament (UCL). Twenty-nine surgically treated patients presenting with a DRHN fracture were classified using the Charalambous classification by 3-dimensional computed tomography. Accordingly, the collateral ligament and overlying muscle injuries and bony contusions were investigated with magnetic resonance imaging. The valgus stress test was performed intraoperatively on 20 patients with magnetic resonance-confirmed complete UCL rupture. If there was no firm end point, the UCL was repaired (group B). The others were treated conservatively (group A). The Minnesota Elbow Performance Score and Disabilities of the Arm, Shoulder and Hand scores were used to measure patient outcome. There was a trend toward a higher incidence of complete UCL rupture in Charalambous type 3D and 4D fractures (P = .110) and complete lateral UCL rupture in Charalambous type 1D and 2D fractures (P = .126), although this was not statistically significant. Rupture of the overlying muscles was more common in group B than in group A (P < .05). Functional outcome between the 2 groups was not significantly different. DRHN fracture is always a complex fracture accompanied by collateral ligament injuries. Type 3D and 4D tended to have a higher association with UCL rupture compared with type 1D and 2D, types commonly associated with lateral UCL rupture. The magnetic resonance imaging-confirmed torn UCL could be managed conservatively if there was a firm end point on valgus stress test.

Articular cartilage changes associated with bony contusions in anterior cruciate ligament injury

Abstract Objectives The goal of the present study was to determine whether a correlation exists between bone contusions sustained with anterior cruciate ligament injury and the articular cartilage changes observed during reconstructive surgery. Methods Across-sectional study was conducted over 5 years for consecutive knees undergoing ACL reconstruction. Clinical data, MRI evaluation, and Arthroscopic findings were reported. Analysis of the data was achieved by using the Fisher’s exact test. Results Thirty six patients with 37 knees were included. Their mean age was 23.9 years. There were 19 males and 17 females. The mean time from injury to MRI was 3 months. The mean time from injury to surgery was 9.86 months. Bone contusions were seen in 30% of medial femoral condyles and medial tibial plateaus. A strong correlation was observed between presence of bone contusions and articular surface damage on the medial femoral condyle (p = 0.026) and the medial tibial plateau (p = 0.011). There were no correlation between bone contusions and articular surface damage on the lateral femoral condyle (p = 1.0) and the lateral tibial plateau (p = 0.69). Conclusion Although lateral compartment bone contusions are more commonly seen following injury, we have not found this to be associated with the status of the overlying cartilage. Degenerative changes in the ACL-deficient knee are multifactorial, but medial compartment bone contusion may be an important contributor that warrants further investigation.

New mechanism of the posterior elbow dislocation

To suggest a new model on the most common kind of posterior elbow dislocation using MRI findings on acute elbow injuries. Fifteen patients with simple elbow dislocation (Group A) and 19 patients sustaining pure ligament injuries (Group B) were enrolled in this study. Using MRI scans, bony contusion at radial head and posterior capitellum (lateral bone contusion) and medial aspect of the ulnohumeral joint (medial bone contusion) were investigated with the injury patterns of the collateral ligament and overlying muscles. In Group A, the injury patterns of the ulnar and lateral ulnar collateral ligaments were classified into distraction or stripping type; in Group B, into rupture or strain. Based on these findings, we speculated the injury mechanism of the elbow dislocation. In Group A, posterolateral (PL) dislocation was found in 12 cases of distractive ulnar collateral ligament type and stripping lateral ulnar collateral ligament type, where lateral bone contusion was found in 11 cases. Posteromedial (PM) dislocation was observed in only two cases of distraction type of the LUCL, where medial bone contusion was seen in two cases. In PL dislocation of the elbow joint, we always found more severe damage of soft tissue at the medial side of the elbow joint compared to the lateral side. Lateral bone contusion was speculated to be caused by bony abutment under pathologic forearm external rotation (PFER) and medial bone contusion, by bony abutment under varus stress. In Group B, the ulnar collateral ligament was more commonly injured than the lateral ulnar collateral ligament, and lateral bone contusion accompanied most cases. PL dislocation is thought to start from the medial side in contrary to PM dislocation beginning at the lateral side. If the disengagement of the coronoid process is not completed due to the insufficient valgus/varus distraction, a coronoid fracture will develop at the same time as the elbow dislocation during PFER.

Traumatic Bone Bruises in the Athlete’s Knee

Context:Mobile water within the bone marrow is a physiological phenomenon that is identifiable on magnetic resonance (MR) imaging, and signal changes can result from blood pooling, reactive hyperemia, edema, and microfracture. When these MR lesions are associated with an acute traumatic event, the findings are referred to as bone bruises and so represent a unique manifestation of injury. This review discusses bone bruises in anterior cruciate ligament (ACL) tears, patella dislocations, occult fractures, and contusions.Methods:A PubMed search of the literature from 1982 to December 2009 was conducted with the terms knee and bone bruise.Results:Bone bruises are associated with ACL tears, patella dislocations, occult fractures, and contusions. For each injury, a unique pattern of bone bruising is found on MR imaging, which results from the acute trauma. When acute trauma produces a subchondral lesion with low T1-weighted and high T2-weighted signal intensity, the resulting bony contusion is best described as a bone bruise.Conclusions:Bone marrow edema is identified using MR imaging and may result from traumatic or atraumatic causes. Bone bruises can be characterized by their pattern at presentation, by the mechanism of injury, and by their associated injuries. This type of bone edema can accompany contact and noncontact ACL ruptures as well as patella dislocations. Although increased marrow edema can be associated with an occult fracture, the long-term significance of these lesions is unclear.

Magnetic resonance imaging of clinically suspected Salter–Harris I fracture of the distal fibula

Objectives In skeletally immature children, isolated lateral ankle injuries without radiograph-visible fractures are often diagnosed with Salter–Harris I fractures of the distal fibula (SH1DF). However, recent magnetic resonance imaging (MRI) evidence in children suggests that sprains may be more common than previously thought. 17 Thus, the main objective of this study was to determine the rate of MRI-confirmed SH1DF among cases where this diagnosis was made presumptively, based on clinical findings. In ankle injuries where there is no MRI evidence of SH1DF, another aim is to detect the pathology which gives rise to this clinical scenario. Methods This was a prospective cohort study performed at a tertiary care paediatric centre. Eligible patients included skeletally immature children with acute ankle injuries presenting with difficulty weight bearing and maximal tenderness and swelling over the distal fibular growth plate (lateral malleolus). Enrolled patients had ankle radiographs at the Emergency Department (ED) visit, MRI within 1 week of the injury, and repeat ankle X-rays at 4 weeks. All images were reviewed by two radiologists and an orthopaedic surgeon. Discrepancies between reading physicians were resolved by consensus agreement. Results Eighteen patients were enrolled into the study from September 2008 to August 2009. Mean (SD) age of participants was 8.7 (2.0) years. None of the 18 patients had evidence of fibular growth plate injury on MR imaging. Patients often had more than one abnormal finding on MRI. Fourteen (78%) had evidence of ligamentous sprains, 11 (61%) had bony contusions, one patient (6%) had a subtle fibular avulsion fracture, and another was found to have a minor articular cartilage injury. At 4 weeks, only one patient's radiographs demonstrated a healing fracture, which corresponded with the avulsion fracture case. All patients had returned to full weight bearing by 4 weeks. Conclusions In this series, the clinical diagnosis of SH1DF was incorrect in 100% of cases. Instead, in almost 90% of these patients, MRI identified ligamentous sprains and/or bony contusions. These results may influence the way children who present with this common clinical scenario are managed since the vast majority of children in this study actually had sprain/contusion injuries and none had SH1DF.

Usefulness of Ultrasonographic Detection of Talocrural Effusion in Ankle Sprains

Ankle sprain severity is difficult to assess initially in the emergency department, yet it governs treatment decisions. Ultrasonography readily shows fluid present in the talocrural joint, which is difficult to assess by physical examination. The purpose of this study was to evaluate the prevalence of ultrasonographic talocrural joint effusion in moderate and severe ankle sprains and to determine the cause of effusions by magnetic resonance imaging (MRI). Consecutive patients 18 to 55 years of age with moderate and severe ankle sprains within the previous 48 hours were included if they had no history of abnormalities in the same ankle within the last 12 months. When ultrasonography with the ankle in the neutral position showed talocrural effusion, MRI was performed within 8 days. Of the 110 patients (83 men and 27 women; mean age, 24.2 years), 40 (36.4%; 95% confidence interval, 27.6%-46.1%) had joint effusion on ultrasonography and MRI. In 39 of these 40 patients, MRI visualized damage to the anterior talofibular ligament (positive predictive value, 97.5%; 95% confidence interval, 85.3%-99.9%), accompanied in 5 (12.8%) cases by damage to the calcaneofibular ligament. In 14 (35%) cases, MRI showed cartilage damage or bony contusion. Talocrural effusion on ultrasonography may identify patients with severe ankle sprains. Magnetic resonance imaging should be performed in patients with talocrural effusion. Further work is needed to evaluate the usefulness of MRI in acute ankle sprains without talocrural effusion.

Lisfranc Fracture Dislocation In A Fencer

HISTORY: A 21 year-old female fencer presented to the training room for a preparticipation physical exam. She grew up in Latvia, where she competed on the national team. One month prior to her arrival, she sustained an inversion injury to her right ankle while competing in a tournament. She was told she had a sprained ankle. Treatment thus far only included crutches and heat. PHYSICAL EXAM: With ambulation there was a noticeable limp when weight bearing on the right foot. The right foot and ankle were swollen, through the dorsum of her midfoot. There was tenderness to palpation of the ATFL, and CFL ankle ligaments. In addition she was tender over the dorsal surface of the forefoot and midfoot. With ankle active range of motion, plantar and dorsiflexion was approximately 5 degrees. Anterior drawer was equal to other side with firm endpoint. Talar tilt was positive for pain but negative for increased laxity. There were no sensory deficits. DIFFERENTIAL DIAGNOSIS: Ankle ligament sprain Midfoot ligament sprain Lateral malleolar fracture Metatarsal and/or tarsal fracture Soft tissue and/or bony contusion TEST AND RESULTS: Ankle anterior-posterior, lateral and mortise view radiographs -No fracture or dislocation noted. Foot anterior-posterior, lateral and oblique view radiographs -Lisfranc fracture dislocation. With a flex sign and dorsal dislocation of the second metatarsal base. FINAL WORKING DIAGNOSIS: Right foot closed displaced Lisfranc fracture dislocation TREAMENT AND OUTCOMES: Referral to orthopedic foot and ankle specialist. Open reduction internal fixation of Lisfranc fracture dislocation with external fixator. Non-weight bearing. Removal of lateral external fixator at 8 weeks post-op. Serial repeat radiographs with and post external fixator, displayed good reduction and healing. Placement in low-tide walking boot, with non-weight bearing for an additional 1–1/2 weeks and initiation of gentle range of motion of ankle and toes. Discontinued boot, weight bearing begun 12 weeks post injury and rehabilitation with athletic training staff started. Rehabilitation included foot and ankle range of motion and strengthening exercises. Along with quadriceps, hamstring and calf strengthening. Athlete returned to sport 8 months after injury. At next season's preparticipation exam athlete reported no foot pain with ambulation or fencing. Athlete was able to meet demands of sport and was cleared to compete again.

Imaging of the collateral ligament injuries of the knee

The role of routine and advanced imaging techniques after suspected injury to the collateral ligaments of the knee is to augment the findings on physical examination. Although radiographs may disclose avulsion injuries, the limited soft tissue contrast does not permit accurate assessment of the collateral ligaments and associated soft tissue structures. Because of its superior soft tissue contrast and multiplanar capabilities, magnetic resonance (MR) imaging has largely replaced conventional imaging techniques. Using high-contrast pulse sequences, MR imaging permits localization of the site of ligamentous trauma, as well as associated soft tissue injury, including meniscal tears, cruciate ligament tears, and injury to the structures of the posterolateral corner. Although secondary signs of ligamentous injury, including adjacent soft tissue edema and bony contusions, may be helpful in localizing the site of injury, the most important criteria remains direct visualization of the ligament, with focal discontinuity. Using such criteria, accurate preoperative assessment of the injured extremity may be made, thereby aiding in the clinical management of the patient.

Traumatic hip dislocation: early MRI findings.

Objective of this study was to present the spectrum of early magnetic resonance imaging (MRI) findings following traumatic dislocation of the femoral head, and to identify any associated injuries that may have therapeutic or prognostic significance and be better delineated by MRI than by conventional radiography. Prospective MRI of both hips was formed on 18 patients (14 male, 4 female; age range 14-54 years; average age 30.5 years) within 5 weeks of a traumatic femoral head dislocation. The interval between the time of injury and the time of injury and the imaging studies ranged from 2 to 35 days (average 13.2 days). Posterior dislocation was present in 14 patients and anterior dislocation in 4 patients. In the majority of cases, we performed axial T1, coronal T1, and coronal T2* (MPGR) sequences. Images were retrospectively evaluated by consensus of three radiologists for possible abnormalities of the bone and cartilage, joint space, and soft tissues. Because all patients were treated with closed reduction, surgical correlation was not obtained. All patients had a joint effusion or hemarthrosis. Of the 14 patients with posterior dislocation, isolated femoral head contusions (trabecular microfractures) were identified in 6 patients. Four patients had small femoral head fractures, and one had an osteochondral defect. Acetabular lip fractures were seen in six patients, and one patient had a labral tear. Four patients had intra-articular loose bodies and one had ligamentum teres entrapment. Twelve patients had iliofemoral ligament injury. All patients had muscle injury involving the gluteal region and medical fascial compartment, and 13 patients had anterior fascial compartment muscle injury. Seven patients with posterior dislocation had posterior fascial compartment injury. Of the four patients with anterior dislocation, two had bony contusion, two had cortical infraction, one had a labral tear, and all four had an iliofemoral ligament injury. All four patients in this group had muscle injury of the gluteal region and of the anterior and medial fascial compartments. MRI can effectively identify and quantify the muscle injury and joint effusion that invariably accompany traumatic hip dislocations. It is also useful for demonstrating trabecular bone contusion (trabecular injury) and iliofemoral ligament injury, which occur commonly with acute hip dislocation.

SPINAL INJURIES IN INFANTS.

The subject of spinal injuries in infants is presented to you in order that a discussion by this body of these injuries will determine their relation to the faulty development of the in the young, and to determine the relation between trauma and spinal caries. The traumatic spine may be defined as any injury to the spinal column. Injuries to the in the very young are not infrequent, though the great majority of such injuries are slight. A simple sprain, muscular or bony contusion, sometimes combined with slight shock, is the usual condition following a slight fall as from a cot or sofa. Again a very slight fall or sudden contact with a sharp corner of an object, may produce a true fracture of the spine, usually a fracture of a spinous process. If a child falls and strikes sideways we may have a green-stick fracture of one