To assess the rates of fractures and ligament injuries in patients with an acute ankle injury and a normal radiographic examination, and to consider the most appropriate examination protocol.
...Patients with an acute ankle injury who presented to the John Radcliffe Hospital Emergency Department with a normal radiographic examination were eligible for the study. They were invited to receive a cone beam CT and ultrasound examination at a local radiology department within 5 days of their ankle injury.
Of the 100 patients recruited to the study, 19 patients were found to have major fractures and 42 patients had small avulsion fractures. Additionally, 42 patients had ankle effusions and there were a large number of soft tissue injuries. There were 83 acute injuries of the anterior talofibular ligament, 19 of the anterior tibiofibular ligaments, 26 of the calcaneofibular ligament, 39 of the deltoid ligament complex, 21 of the talonavicular ligament, 14 of the spring ligament and 3 of the calcaneocuboid ligament.
Conventional radiographic examination misses significant fractures of the foot and ankle and the presence of an ankle effusion does not relate to the severity of injury. Ultrasound is a useful imaging technique that can supplement clinical practice, but it is unlikely to replace current protocols alone. Cone beam CT is an appropriate alternative to plain radiography, being more sensitive in detecting fractures and delivering a similar dose of radiation. However, neither CT or ultrasound examination can detect all avulsion fractures. Simple anterior process fractures of the calcaneus are associated with talonavicular ligament injuries and the medial ligaments are injured in almost 50% of cases when there is a lateral ligament injury.
Fractures in the foot and ankle are detected more precisely with cone beam CT compared to radiographs. Cone beam CT delivers similar doses of to conventional radiographs which is around 10% of that resulting from conventional CT. Ultrasound examination is an effective assessment tool to detect ligamentous injuries. The absence of an ankle effusion does not exclude a major fracture.
Objectives
To update the 2012 European Society of Musculoskeletal Radiology (ESSR) clinical consensus guidelines for musculoskeletal ultrasound referral in Europe.
Methods
Twenty-one musculoskeletal ...imaging experts from the ESSR participated in a consensus study based on a Delphic process. Two independent (non-voting) authors facilitated the procedure and resolved doubtful issues. Updated musculoskeletal ultrasound literature up to July 2017 was scored for shoulder, elbow, wrist/hand, hip, knee, and ankle/foot. Scoring of ultrasound elastography was included. The strength of the recommendation and level of evidence was scored by consensus greater than 67% or considered uncertain when the consensus was consensus less than 67%.
Results
A total of 123 new papers were reviewed. No evidence change was found regarding the shoulder. There were no new relevant articles for the shoulder, 10 new articles for the elbow, 28 for the hand/wrist, 3 for the hip, 7 for the knee, and 4 for the ankle/foot. Four new evidence levels of A were determined, one for the hip (gluteal tendons tears), one for the knee (meniscal cysts), one for the ankle (ankle joint instability), and one for the foot (plantar plate tear). There was no level A evidence for elastography, although for Achilles tendinopathy and lateral epicondylitis evidence level was B with grade 3 indication.
Conclusions
Four new areas of level A evidence were included in the guidelines. Elastography did not reach level A evidence. Whilst ultrasound is of increasing importance in musculoskeletal medical practice, the evidence for elastography remains moderate.
Key Points
• Evidence and expert consensus shows an increase of musculoskeletal ultrasound indications.
• Four new A evidence levels were found for the hip, knee, ankle, and foot.
• There was no level A evidence for elastography.
The current lack of agreement regarding standardised terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice and research. This consensus was ...developed to provide a reference to improve clarity and consistency in communication. A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus, which was defined as group level agreement of >80%. Content was organised into seven general topics including: (1) general definitions, (2) equipment and transducer manipulation, (3) anatomical and descriptive terminology, (4) pathology, (5) procedural terminology, (6) image labelling and (7) documentation. Terms and definitions which reached consensus agreement are presented herein. The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients and third-party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound-guided procedures related to musculoskeletal and sports medicine.
Sprained ankles are common and when there are no signs or evidence of a fracture, conventional management is conservative. At present, there are no clinical markers to identify those that may develop ...persisting instability and disability that would require rehabilitation or surgery.
To investigate the nature and extent of soft tissue ankle injuries, and to consider whether the anatomical severity of injury can predict functional outcome.
Patients attending a local Accident and Emergency Department in Oxford with an acute ankle injury with no clinical requirement for radiographs, or where radiographs were normal, were invited into the study. Within 5 days, patients underwent a diagnostic ultrasound examination, a cone beam CT study and a disability assessment. Ultrasound and physiotherapy assessments were repeated at 3 and 6 months.
100 patients were recruited and grouped based upon injuries. 58 had simple ankle injuries, 21 complex, 19 had significant fractures and 2 were excluded from further follow up analysis. There were no clinically significant differences in pain, disability or functional outcomes between the groups at all points of the study.
Medium to long term clinical outcomes were not solely determined by the severity of injury. Some patients with simple injuries were seen to have ongoing problems, whereas some with complex injuries recovered completely in a shorter period. Advances in knowledge: The severity of an ankle injury determined by radiological imaging does not necessarily dictate the severity of a patient's symptoms and the trajectory of their recovery.
Objectives
The current lack of agreement regarding standardized terminology in musculoskeletal and sports ultrasound presents challenges in education, clinical practice, and research. This consensus ...was developed to provide a reference to improve clarity and consistency in communication.
Methods
A multidisciplinary expert panel was convened consisting of 18 members representing multiple specialty societies identified as key stakeholders in musculoskeletal and sports ultrasound. A Delphi process was used to reach consensus which was defined as group level agreement >80%.
Results
Content was organized into seven general topics including: 1) General Definitions, 2) Equipment and Transducer Manipulation, 3) Anatomic and Descriptive Terminology, 4) Pathology, 5) Procedural Terminology, 6) Image Labeling, and 7) Documentation. Terms and definitions which reached consensus agreement are presented herein.
Conclusions
The historic use of multiple similar terms in the absence of precise definitions has led to confusion when conveying information between colleagues, patients, and third‐party payers. This multidisciplinary expert consensus addresses multiple areas of variability in diagnostic ultrasound imaging and ultrasound‐guided procedures related to musculoskeletal and sports medicine.
To assess the prevalence of injury of the talonavicular ligament (TNL) in ankle sprains, its anatomy and the stability of the talonavicular joint (TNJ) before and after dividing the TNL in a cadaver.
...During a prospective study of 100 patients to assess the outcome of ankle injuries, we noted high incidence of TNL injuries; we will discuss here the TNL findings. Each patient had undergone ultrasound and cone beam CT examination of the ankle. Six TNLs were dissected off fresh-frozen cadaveric feet for histological analysis. In further six cadaveric feet, the stability of the TNJ was assessed by mechanical stress before and after division of the TNL; movement at the joint was assessed by measuring the distance between the talus and navicular bone talonavicular distance (TD) using ultrasound. The TD was measured on ten randomly selected ultrasound images by three independent observers and repeated twice by a single observer to determine the inter- and intraobserver reliability.
21% of the patients had an injury to the TNL. Histological examination demonstrated a dense connective tissue composed of bundles of collagen in parallel arrangement along the ligament length. The interobserver and intraobserver reliability of the TD showed almost perfect agreement. Displacement at the TNJ after stress with the TNL intact measured 0.18 ± 0.08 cm and 0.29 ± 0.07 cm (p < 0.005) when divided.
The TNL is surprisingly commonly injured in ankle sprains. Its anatomy and histology suggest a role in tensile force transmission during the windlass mechanism in gait. Advances in knowledge: Injury to the TNL is common and has not been described. Its anatomy suggests resistance to tensile forces and its injury allows excessive movement at the TNJ.
Imaging of the limping child Bartoloni, Alessandra; Aparisi Gómez, Maria Pilar; Cirillo, Marco ...
European journal of radiology,
December 2018, 2018-Dec, 2018-12-00, 20181201, Letnik:
109
Journal Article
Recenzirano
•Limping can be a diagnostic challenge in the pediatric patient.•Imaging approach can be differentiated according to three age groups.•An imaging algorithm can be narrowed down by the ...presence/absence of a history of trauma and systemic symptoms of infection.•Numerous anatomical variants and developmental changes are normal findings in the immature skeleton.
Limping is a challenging symptom in the pediatric patient as the diagnosis can range from traumatic, malformative, infectious/inflammatory and neoplastic diseases.
In this paper, we propose a schematic imaging algorithm to the limping child in three different age groups (Toddler: 1–3years, child: 4–10 years; adolescent: 11–16 years) based on presence of signs of infection, any specific localization of pain, and history of trauma. In this setting, the most common imaging pitfalls are also summarised. Finally, a literature review of the main differential causes of limping in the pediatric patient is reported.
Ultrasound is a powerful screening examination for athletes with upper limb injuries. It is very effective in demonstrating injuries to muscle, tendon, ligament, and nerves. The technique is ...particularly useful in excluding joint effusion and in detecting soft tissue foreign bodies. Dynamic ultrasound examination is especially useful in detecting subluxation of tendon and nerves; it may be the only means of demonstrating the cause of snapping. Detailed anatomical knowledge is mandatory, and the examination should be structured and systematic. Ultrasound may overlook disorders of the deep structures in joints and bone disease. Those employing the technique must understand the strengths of ultrasound examination compared with and in combination with MRI.
Pain around the hip and pelvis is a very common condition. Pain may be generated within the joint space (i.e. the hip joint itself, the sacroiliac joints or the pubic symphysis) or from surrounding ...myotendinous, bursal, or nerve structures. Over the years, percutaneous musculoskeletal procedures have become increasingly popular to diagnose and treat painful conditions around the hip and the pelvis. Most intra- and extra-articular procedures are performed under ultrasound guidance. This article reviews the most common diagnostic and therapeutic procedures that can be performed around the hip and the pelvis under ultrasound guidance.
The provenance of sand-sized ice-rafted debris (IRD) sourced from Greenland is currently difficult to determine. Such knowledge, if it could be ascertained with a high degree of certainty, could be ...applied to the Greenland-proximal marine records to improve both our understanding of modern-day spatial patterns of iceberg rafting and the past history of the Greenland Ice Sheet (GIS). Recent studies have highlighted the utility of the Pb-isotope composition of individual sand-sized feldspars and the 40Ar/39Ar ages of individual sand-sized hornblendes in this regard. However, before any such provenance toolkit can be applied to the palaeo-record, it is necessary first to determine whether this approach can be used to track the sources of known recent Greenland-proximal IRD deposition. To this end we present new records of the Pb-isotope composition and the 40Ar/39Ar ages of individual sand-sized grains of feldspars and hornblendes, respectively, from modern Greenland glacifluvial and fjord sands and Holocene to modern Greenland-proximal marine sediments. These new data demonstrate that sand-sized feldspars and hornblendes glacially eroded by the GIS exhibit distinct intra- and inter-tectonic terrane differences in their Pb-isotope compositions and ages and that these differences are clearly expressed in the geochemistry and geochronology of sand-sized IRD deposited in marine sediments around Greenland. Although overlap exists between some Greenland-proximal IRD ‘source fields’ defined by these data, our approach has the potential to both better understand spatial patterns of Greenland-derived IRD in the modern day as well as during past episodes of iceberg calving.
•We measure feldspar Pb-isotopes and date hornblende in Greenland river sands.•We use these data to determine spatial variation in Holocene IRD provenance.•We demonstrate how our approach can be used to reconstruct ice-margin histories.
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