Preliminary Radiographs Research Articles

A Rare Cause of Acute Abdomen in Adults: Adult Intussusception

Adult intussusception is rare, less common and differs from childhood intussusception in its presentation, aetiology and treatment. It is common in paediatrics of less than three years of age.1,2 Unlike in paediatric population, most adult cases presented to emergency department with intestinal obstruction, and rarely, the actual diagnosis of intussusception is made during clinical setting. Top causes of adult intussusception include malignant or benign lesions, post-operative complications such as adhesions, Meckel diverticulum and bowel inflammatory disease. 8-20% of cases are idiopathic with no lead point lesion.3 Preliminary radiograph may show signs of intestinal obstruction, but computed tomography (CT) is the gold standard imaging for intussusception. This is a case report of an adult intussusception in Hospital Tengku Ampuan Afzan, Kuantan which was not detected during clinical examination, but diagnosed by CT imaging.

Abnormal Presentation of a Plastic Foreign Body in The Retropharyngeal Space.

Abstract We present a case of a plastic foreign body that was initially not identified despite preliminary radiographs. Penetrating foreign bodies located in the retropharyngeal space carry a high risk of mortality due to their proximity to the carotid sheath. Foreign bodies left in situ may lead to a number of complications notably infection or fistulae. To limit the risks associated with these injuries timely diagnosis with appropriate imaging is vital. Unfortunately, plastic foreign bodies can be difficult to visualize on standard imaging modalities which can complicate diagnosis.

Direct Sinus Lift and Immediate Loading of Dental Implant– Clinical Reports and Preliminary Radiographic Results

Direct Sinus Lift and Immediate Loading of Dental Implant– Clinical Reports and Preliminary Radiographic Results

Spectrum of imaging findings in trans-gastric migration of accidently ingested metallic foreign bodies

Background: An accidently ingested foreign body may get lodged within the lumen of gastrointestinal tract, pass uneventfully with feces or may migrate extraluminally into the surrounding tissues in which case it may lead to suppurative or vascular complications. The aim of the endeavor was to study the spectrum of imaging findings in patients with accidental ingestion of foreign bodies with trans-gastric migration of metallic foreign bodies.Methods: Total 33 patients with history of accidental ingestion of foreign bodies were subjected to preliminary radiograph of neck, chest and abdomen followed by upper gastrointestinal endoscopy. Failure to retrieve/ localize foreign body endoscopically from upper gastrointestinal tract with check radiograph reiterating the presence of foreign body in upper abdomen were subjected to computed tomography of abdomen.Results: A total of 33 patients comprising of 27 females and 6 males with mean age of 23.76 years with history of foreign body ingestion were studied. Ingested foreign bodies were lodged in pharynx (n=7), esophagus (n=3), stomach (n=13) or duodenum (n=3). In 7 patients in whom endoscopy failed to locate and/or retrieve foreign body, computed tomography confirmed the presence of trans-gastrically migrated foreign body in the surrounding structures. The location of migrated foreign bodies was in lesser sac (n = 2), greater omentum (n = 3), lesser omentum (n = 1) and transmural (n = 1). Two patients had evidence of collection formation around the migrated foreign bodies.Conclusions: Sharp or pointed metallic foreign bodies may migrate trans-luminally with various implications. Though radiography is the preliminary workhorse for the confirmation of ingested foreign bodies, computed tomography owing to its volumetric data acquisition helps in exact localization of migrated foreign bodies and should precede any therapeutic intervention for retrieval of migrated foreign bodies.

An unusual presentation of an epidermoid inclusion cyst of the finger misdiagnosed as a lipoma

Epidermoid cyst is a developmental cyst filled with keratinous material and lined by stratified squamous epithelium similar to the skin. They usually present cutaneously in the back and neck. Their etiology is unknown and has been linked directly to trauma. We report a similarly rare occurrence of an epidermoid cyst in the finger of a 25-year-old male. We report an unusual presentation of an epidermoid inclusion cyst of the fourth finger in a 25-year-old man. The patient was misdiagnosed as a lipoma of the finger initially. The patient was successfully treated by excision and biopsy after preliminary radiographs. Epidermoid inclusion cyst of the finger is rare. This condition presents a diagnostic challenge due to the absence of consistent symptoms and triggering factors. The recurrence rate of these lesions is low.

Pre-procedural scout radiographs are unnecessary for routine pediatric fluoroscopic examinations.

Although practice patterns vary, scout radiographs are often routinely performed with pediatric fluoroscopic studies. However few studies have evaluated their utility in routine pediatric fluoroscopy. To evaluate the value of scout abdomen radiographs in routine barium or water-soluble enema, upper gastrointestinal (GI) series, and voiding cystourethrogram pediatric fluoroscopic procedures. We retrospectively evaluated 723 barium or water-soluble enema, upper GI series, and voiding cystourethrogram fluoroscopic procedures performed at our institution. We assessed patient history and demographics, clinical indication for the examination, prior imaging findings and impressions, scout radiograph findings, additional findings provided by the scout radiograph that were previously unknown, and whether the scout radiograph contributed any findings that significantly changed management. We retrospectively evaluated 723 fluoroscopic studies (368 males and 355 females) in pediatric patients. Of these, 700 (96.8%) had a preliminary scout radiograph. Twenty-three (3.2%) had a same-day radiograph substituted as a scout radiograph. Preliminary scout abdomen radiographs/same-day radiographs showed no new significant findings in 719 (99.4%) studies. New but clinically insignificant findings were seen in 4 (0.6%) studies and included umbilical hernia, inguinal hernia and hip dysplasia. No findings were found on the scout radiographs that would either alter the examination performed or change management with regard to the exam. Pre-procedural scout abdomen radiographs are unnecessary in routine barium and water-soluble enema, upper GI series, and voiding cystourethrogram pediatric fluoroscopic procedures and can be substituted with a spot fluoroscopic last-image hold.

Diagnostic Accuracy of Charge-coupled Device Sensor and Photostimulable Phosphor Plate Receptor in the Detection of External Root Resorption In Vitro.

Background and aims. Early diagnosis of external root resorption is important for accurate treatment. The purpose of this study was to compare the efficacy of a charge-coupled device (CCD) sensor and a photostimulable phosphor (PSP) plate receptor in the diagnosis of artificial external root resorption.Materials and methods. In this diagnostic in-vitro study, 40 maxillary incisors were mounted in a segment of dry bone and preliminary radiographs were obtained using CCD and PSP sensors. Artificial resorption cavities were produced on the middle-third in half of the samples and on the cervical-third in the other half on the buccal root surfaces. Radiographs were repeated and images were evaluated. Data were statistically analyzed using chi-square and diagnostic tests.Results. There were no significant differences between the two sensors in the sensitivity (p=0.08 and 0.06) and specificity (p=0.13) for the diagnosis of resorption in both root areas. The overall accuracy of CCD was higher than PSP sensor; however, the difference was not statistically significance (p>0.05).Conclusion. CCD and PSP sensors chosen for the present study produced similar results in diagnosing simulated external root resorption.

Orthogonal Radiographic Technique for Radiographic Visualization of Coracoid Process Fractures and Pericoracoid Fracture Extensions

Radiographic visualization of coracoid process fractures is difficult due to the complex and variable 3-dimensional orientation of coracoid pillars. Failure to suspect an injury on preliminary radiographs has been described as a major reason for suboptimal management of these fractures. We describe a standardized method of patient positioning and radiographic beam angulation (orthogonal radiographic technique), to provide two roentgenographic views (Bhatia views) for visualization of individual coracoid pillars. The "superior pillar view (SPV)" demonstrates fractures involving the superior pillar, and peri-coracoid extension into the suprascapular notch; the "inferior pillar view (IPV)" is useful for fractures involving the inferior pillar (coracoid base), and their extension into the glenoid articular surface. Radiographs of 19 consecutive coracoid fractures, that were imaged using the described technique, were analyzed, and the results were used to suggest a radiographic method of grouping these injuries.

Allograft Cellular Bone Matrix in Extreme Lateral Interbody Fusion: Preliminary Radiographic and Clinical Outcomes

Introduction. Extreme lateral interbody fusion (XLIF) is a minimally disruptive alternative for anterior lumbar interbody fusion. Recently, synthetic and allograft materials have been increasingly used to eliminate donor-site pain and complications secondary to autogenous bone graft harvesting. The clinical use of allograft cellular bone graft has potential advantages over autograft by eliminating the need to harvest autograft while mimicking autograft's biologic function. The objective of this study was to examine 12-month radiographic and clinical outcomes in patients who underwent XLIF with Osteocel Plus, one such allograft cellular bone matrix. Methods. Forty (40) patients were treated at 61 levels with XLIF and Osteocel Plus and included in the analysis. Results. No complications were observed. From preoperative to 12-month postoperative followup, ODI improved 41%, LBP improved 55%, leg pain improved 43.3%, and QOL (SF-36) improved 56%. At 12 months, 92% reported being “very” or “somewhat” satisfied with their outcome and 86% being either “very” or “somewhat likely” to choose to undergo the procedure again. Complete fusion was observed in 90.2% (55/61) of XLIF levels. Conclusions. Complete interbody fusion with Osteocel Plus was shown in 90.2% of XLIF levels, with the remaining 9.8% being partially consolidated and progressing towards fusion at 12 months.

Interleukin-1 beta, interleukin-6 and TGF-beta in follicular tissue of impacted third molars

The clinical evaluation and management of impacted third molars remain challenging. The aim of the present study was to investigate possible associations between follicular tissue cytokines and radiographic manifestations of impacted third molar. The population included 72 patients who underwent surgical extraction of impacted third molars. All these patients underwent a preliminary panoramic radiograph. Levels of interleukin-1 beta (IL-1β), interleukin-6 (IL-6) and transforming growth factor beta (TGF-β) in tissue extracts were determined using ELISA. There were no significant differences between bony and tissue impaction as regards IL-1β, IL-6 and TGF-β levels. Moreover, the same results were obtained as far as the amount of pericoronal space and the presence or absence of a history of pericoronitis are concerned. These results suggest that radiographic findings or a history of pericoronitis are not associated with levels of expression of pro-inflammatory cytokines in patients undergoing surgical removal of impacted third molars. However, further studies are needed to address the possibility of variability during disease progression.

Immediate Loading of Dental Implant After Sinus Floor Elevation With Osteotome Technique: A Clinical Report and Preliminary Radiographic Results

Edentulous ridges in the posterior maxilla are often compromised by reduced bone volume. This anatomic condition often limits dental implant placement of 10 mm in length without prior or simultaneous sinus augmentation. The osteotome technique is an alternative and conservative technique for sinus floor augmentation and immediate implant placement in the posterior region of the maxillary jaw. According to the relevant literature, the osteotome technique appears to be a predictable and safe method for augmenting bone at the sinus floor and to improve bone density and quality of the implant site sufficiently so that immediate loading is possible. A 46-year-old male patient was referred to the authors to replace the single upper premolar with an implant-supported crown restoration without interfering with the integrity and topography of the adjacent gingival tissues. Only one clinical study analyzed minimally invasive implant and sinus lift surgery with immediate loading. In that case report, the osteotomy was widened to its final diameter using a series of incrementally larger twist drills. In our clinical case, a series of incrementally larger diameter osteotomes improved bone density. This simplified treatment modality can make single tooth implant rehabilitation of the atrophic premolar maxilla region more accessible, and immediate loading is facilitated by improved bone density.

Superficial Lymphatic System of the Upper Torso: Preliminary Radiographic Results in Human Cadavers

Lymphoscintigraphy has become a routine examination for identifying the sentinel lymph node in various cancer patients. Despite increasing clinical information, the basic anatomy of the superficial lymphatic system of the upper torso has not been fully elucidated. Five female breasts, three anterior chest walls, and three forequarter specimens from fresh nine cadavers (two male and seven female) were used for this study. Our original radiographic method for delineating the lymphatics was applied. The course of the lymph vessels was traced from the x-ray films and color coded in accordance with their sentinel lymph node to define the lymph territories of the upper torso. In addition, cross-sectional studies were performed on the female breasts to demonstrate the three-dimensional pathway and connections of the lymphatic vessels. The lymphatic territories of the upper torso were divided by the midaxillary line. The anterior side drained into the external mammary or axillary vein lymph nodes and the posterior side drained into the scapular nodes. There was no significant difference between sexes. In most cases, one sentinel lymph node in the axilla notably covered a large lymph territory in both the upper arm and the upper torso. The authors have demonstrated by radiography and dissection the superficial lymphatics of the upper torso in male and female cadavers. The lymph vessels originating in the lower region of the upper torso have close spatial association with the breast tissue and seemed to play a key role in the breast lymph drainage.

Making Preliminary Radiographic Reports Available to Referring Clinicians: Current Status

To investigate current practice regarding the release of resident's preliminary imaging reports to physicians providing clinical care to patients. The second objective was to evaluate compliance with the American College of Radiology (ACR) practice guidelines. With the assistance of the Society of Chairman of Academic Radiology Departments (SCARD), a survey was sent to its members. This survey asked if members felt that residents' preliminary reports should be released to referring physicians. If yes, the survey requested information as to how this was done and the mechanism by which the referring physicians were informed that the report was preliminary. Twenty-eight surveys were completed. Twenty-five respondents felt that preliminary reports should always be made easily available to referring physicians; three did not. In 25 of 28 institutions, the referring clinicians can obtain preliminary information by talking to the trainee face-to-face or by phone. In 12 institutions, clinicians could obtain preliminary reports by phoning into the hospital dictation system and listening to the dictated report. Twenty-six of the 28 institutions permit referring clinicians to obtain preliminary reports by viewing/reading these reports in picture archiving and communication system (PACS) or hospital information system (HIS) systems, before they are finalized. Almost all academic radiology departments responding to this survey do make electronic trainee reports available to referring clinicians. Compliance with ACR guidelines is good, but not perfect. Most institutions no longer provide the ability to listen to the dictation.

A Complex Knee Injury in an Adolescent Football Player

HISTORY: A 18-year-old senior HS football player presented to the University of Chicago Sports Medicine clinic with a chief complaint of 4 days of severe left knee pain. His injury occurred during a football game when he was tackled around his left ankle causing his foot to be effectively planted, he fell back with his knee extended then turned to the right resulting in a painful “pop”. Preliminary radiographs in the ED were read “no fracture”. He was discharged NWB with crutches and an immobilizer. In clinic he still had severe pain, swelling, limited motion and was unable to bear weight. PMH: healthy MEDS: Tylenol #3's prn and ibuprofen 800 mg po tid SPORTS: Pt signed a full ride college scholarship for football 1 week prior. PHYSICAL EXAMINATION: On examination the patient was 6 feet tall, 250 lbs. He had a 3+ joint effusion and a 15 degree flexion contracture with 20 degrees of motion. MCL, LCL anteromedial and anterolateral joint lines were tender. He could not perform a quad set. DIFFERENTIAL DIAGNOSIS: ACL tear with or without associated injuries Fracture of femur and/or tibia Meniscal tear with possible mechanical block Osteochondral injury with or without loose body Quad tendon tear TEST AND RESULTS: AP, lateral and oblique left knee radiographs from the ED were interpreted in clinic as a displaced tibial spine avulsion fracture. The radiologist interpretation was a “loose body”. FINAL WORKING DIAGNOSIS: Displaced Tibial Spine Avulsion with ACL deficiency TREATMENT AND OUTCOMES: The patient had a knee arthroscopy performed 9 days post-injury. Findings included ACL insufficiency, tibial spine avulsion fracture, an impaction fracture of the posterior lateral tibial plateau, a bucket handle tear of the lateral meniscus and a complex vertical 1.5 cm medial meniscal tear. Multiple bone fragments, cartilage pieces, and frayed ligament tissue were removed. The meniscal tears were debrided and repaired. An ACL reconstruction using a bone-patellar-bone graft was performed. The impaction fracture site was debrided. Full ROM noted in the OR. Post-op therapy is progressing with the hope of playing football next season. Discussion points of this case include age-related complications of ACL injury including tibial spine injuries as well as indications for early surgical intervention and treatment options.

False-positive preliminary radiograph interpretations in a pediatric emergency department: Clinical and economic impact

A prospective, case control study at a university-affiliated, academic pediatric emergency department was undertaken to determine the clinical impact and cost of false-positive preliminary radiograph interpretations and to compare the cost of false-positive interpretations with the estimated cost of a 24-hour on-site pediatric radiologist. Data were collected on all patients undergoing radiography of the chest, abdomen, lateral (soft tissue) neck, cervical spine, or extremities during a 5-month period. A total of 1,471 radiograph examinations was performed, and 200 (14%) misinterpretations (false-positive and false-negative) by the pediatric emergency medicine physicians were identified. As reported previously, 20 (10%) of the false-negative interpretations were noted to be clinically significant. In the current analysis, 103 (7%) false-positive radiograph interpretations were identified. False-positive interpretations were noted more frequently (14%) for soft tissue lateral neck radiographs than for any other radiograph type. Of the 103 total false-positive radiographs, nine (0.6%) resulted in an increased patient cost totaling $764.75. These data show that false-positive radiograph interpretations have limited economic and clinical impact.

Localization of specific joint causing hindfoot pain: value of injecting local anesthetics into individual joints during arthrography.

The purpose of this study was to evaluate the utility of selective injection of local anesthetic into hindfoot articulations for localizing the source of posttraumatic pain and to compare clinical response with the severity of degenerative change in the various articulations evident on plain radiographs or CT scans. Anesthetic arthrography was performed in 18 patients with posttraumatic hindfoot pain. In all, 32 joints were assessed: 15 talocalcaneonavicular, 11 subtalar, five ankle, and one calcaneocuboid. Following intraarticular injection of a mixture of equal amounts of meglumine diatrizoate 60%, lidocaine 1%, and bupivacaine 0.25%, patients were asked to grade the degree of pain relief they experienced on a scale from 0% to 100%. The degree of degenerative changes seen on preliminary radiographs and CT scans was graded blindly and retrospectively by an experienced musculoskeletal radiologist using a 3-point scale (grade 0 indicated a normal joint, grade 1 indicated mild to moderate degenerative change, and grade 2 indicated severe degenerative change). The value of findings on both routine radiographs and CT scans as predictors of the degree of symptomatic relief obtained from specific joint injections was determined. Arthrodesis was performed in nine patients on the basis of the results of anesthetic injections. The degree of pain relief experienced after intraarticular injection of anesthetic correlated with the severity of degenerative change as assessed by routine radiography in 15 of 32 joints and as assessed by CT in eight of 18 joints. In 14 of 32 joints assessed by routine radiography and in seven of 18 joints assessed by CT, the amount of pain relief achieved by anesthetic arthrography was less than that predicted by imaging evidence of degenerative disease. In five of 32 joints judged normal on plain film radiographs, significant pain relief was experienced following anesthetic injection, resulting in a change in the proposed surgical procedure. Long-term follow-up indicated satisfactory results in eight of the nine patients in whom arthrodesis was performed. Selective intraarticular anesthetic injections afford a direct method of confirming the site of hindfoot pain and may aid in surgical planning, because plain film radiography or CT may underestimate or poorly indicate the most symptomatic articulations.

The Bronze Hut Urn in the Metropolitan Museum of Art: Technical Report

WHEN THE URN was first examined, a survey was made of the corroded surface. While it was rapidly realized that much of the supposed corrosion was actually paint, the metal beneath the paint in general looked rather convincingly old. This suggested that the urn had been partially stripped and repatinated but might otherwise be authentic. Preliminary radiographs revealed a bewildering network of solder seams in unexpected places, despite the external evidence that the object was riveted together. Once it was noted that the eight rivets fastening the roof to the urn had been soft-soldered in place rather than headed over, they were easily unsoldered and the roof was removed. In addition to

High-speed, single-screen/single-emulsion film systems: basic imaging properties and preliminary clinical applications.

We investigated the potential clinical use of single-screen/single-emulsion film systems by comparing their relative speeds, modulation transfer functions (MTFs), Wiener spectra, and H & D curves with those of conventional screen-film systems. The relative speeds of single screens with single-emulsion Kodak OM film (single systems) were 50-60% lower than those of the conventional double screens with double-emulsion Kodak OG film (double systems), but the single systems yielded a 75-110% increase in the MTF at 2 cycles/mm. The single system had a noise level comparable to or slightly greater than that of the double systems. Phantom images and preliminary clinical radiographs indicated that single systems can improve image resolution over that obtainable with double systems under the same exposure conditions. More importantly, the use of a single system provided an approximately 40% reduction in patient exposure while providing a comparable radiographic image quality.

Suprapelvic phleboliths: Prevalence, distribution and clinical associations

The preliminary radiographs of 783 patients undergoing excretory urography were prospectively surveyed for the presence of abdominally located phleboliths. Two per cent demonstrated typical densities in a periureteral distribution flanking the lumbar spine where they could be confused with ureteral calculi. All these patients were multiparous females and three-quarters of them had pelvic masses (11% of all patients with pelvic masses), suggesting a possible association with gonadal vein thrombi. Altered venous flow with dilatation of ovarian veins, consequent valvular incompetence and stasis may account for the gonadal vein distribution in the pelvic mass cases. Other observed clinical conditions included hepatic disease, portal hypertension and varices. Obstruction and stasis of venous flow in hepatic disease states may lead to phlebolith formation in gastric and mesenteric varices. Unlike pelvic phleboliths, suprapelvic phleboliths are infrequent but may be detected by careful inspection of low kilovoltage films, particularly in the regions closely flanking the lumbar spine. Their presence may be associated with pelvic masses or significant chronic hepatic disease and they may be confused on plain film with ureteral calculi.

Preliminary radiograph for barium enema examination: is it necessary?

In a study of 200 barium enema examinations, the value of the preliminary radiograph, both in demonstrating abnormalities not detectable on the contrast radiographs and in showing the amount of residual fecal material in the colon, was assessed. No clinically significant abnormalities were seen on the preliminary film alone. Estimation of residual fecal material from the preliminary radiograph was frequently faulty and could have resulted in needless additional preparation of patients. This study suggests that inclusion of the preliminary radiograph does not affect the overall diagnostic accuracy of the barium enema examination. Its elimination would yield large savings in health care costs and radiation exposure.