Transvaginal Ultrasound Appearances of the Ovary in Normal Women and Hirsute Women with Oligomenorrhoea.
Fox R (Univ of Bristol, England)
Aust NZ J Obstet Gynaecol 39:63-68,1999.
Conclusion – In women with polycystic ovary disease, the classical ultrasound features are not consistently present, and the absence of increased follicularity at scan does not exclude a diagnosis of polycystic ovary. The diagnosis could be made with 15 or more small follicles per ovary. An expanded echogenic ovarian stroma was found in all the women with hirsuitism.
Lesley ME McCowan, Jane E Harding, Alistair B Roberts, Sarah E Barker, Cassandra Ford, and Alistair W Stewart. (Dept. of Obstetrics & Gynaecology, Univ of Auckland).
A Pilot Randomized Controlled Trial of Two Regimens of Fetal Surveillance for Small-for-Gestational-Age Fetuses with Normal Results of Umbilical Artery Doppler Velocimetry.
Am J Obstet Gynecol 2000; 182:81-6.
Objective : This study was undertaken to determine whether the frequency of fetal surveillance could be safely reduced from twice weekly to fortnightly in the case of small-for-gestational-age fetuses with normal results of umbilical artery Doppler velocimetry studies.
Study Design: Pregnant women between 24 and 36 weeks’ gestation (n=167) with small-for-gestational-age fetuses and normal results of umbilical artery Doppler velocimetry studies were randomly allocated to undergo twice-weekly or fortnightly fetal surveillance. Statistical analysis was carried out according to intention to treat.
Results: Eighty-five women were randomly assigned to undergo twice-weekly fetal surveillance and 82 were randomly assigned to undergo fortnightly fetal surveillance. Those randomly assigned to twice-weekly surveillance were delivered 4 days earlier (264 vs 268 days; P= .04) and were more likely to have labor induced (n=70, 82%, vs n=54, 66%; P= .02) than those randomly assigned to fortnightly surveillance. Fifty-four babies (23%) were admitted to the neonatal nursery, but there were no differences in neonatal morbidity between the groups.
Conclusions: Maternal intervention (induction) was more common in the twice-weekly group. No differences in neonatal outcomes were detected. A much larger trial is required to determine the safety and potential benefits of less frequent surveillance of small-for gestational-age fetuses with normal results of umbilical artery Doppler velocimetry studies.
Ellenbecker TS, Mattalino AJ, Elam EA, et al [ Scottsdale Sports Clinic, Ariz; Clinical Diagnostic Radiology Ltd, Phoenix, Ariz; Milwaukee Brewers Baseball Club, Milwaukee, Wis]
Medial Elbow Joint Laxity in Professional Baseball Pitchers: A Bilateral Comparison Using Stress Radiography
Am J Sports Med 26: 420-424, 1998
Baseball pitching and other throwing athletes places repetitive valgus stress on the elbow leading to ulnar collateral ligament injury. This study compared medial elbow laxity in the throwing and non-throwing arms of 40 professional baseball pitchers.
The clinical range of motion of the elbows and wrist and bilateral stress radiography was done and the laxity was calculated by measuring joint space width between the trochlea and the coronoid process on anteroposterior radiographs.
The dominant arm showed greater medial joint width and reduced range of movement [particularly extension] than the non dominant arm.
They conclude that professional baseball pitchers show increased medial elbow laxity in the throwing arm than the other arm. Stress radiography is a reliable test to demonstrate this.
Lee GA, Katz SD, Lazarus MD [Albert Einstein Med Ctr, Philadelphia]
Elbow Valgus Stress Radiography in an Uninjured Population
Am J Sports Med 26: 425-427, 1998
Valgus instability of the elbow is usually diagnosed clinically, though some have used gravity valgus stress radiography to aid in diagnosis. The amount of ulnahumeral gapping was measured in normal elbows by this method.
40 asymptomatic people [ 20 men and 20 women] mean age [ 27 years] were studied. Both elbows were radiographed with the elbows in extension and in 300 flexion. Medial ulnahumeral distance was measured in 3 situations. [a] No stress [b] gravity valgus stress [c] applied valgus stress.
The ulnahumeral distance increased significantly with increasing stress.
They conclude that even in normal elbows valgus stress causes significant increase in ulnahumeral distance. This test could be used for diagnosis of valgus instability in injured patients but is of no value in uninjured elbows.
Bernicker JP, Hadded JL, Lintner DM, et al [Baylor college of Medicine, Houston]
Patellar Tendon Defect During the First Year After Anterior Cruciate Ligament Reconstruction: Appearance on Serial Magnetic Resonance Imaging
Arthroscopy 14: 804-809, 1998
ACL rupture is commonly repaired using the central third of the patellar tendon. The healing process of the patellar tendon has been chronicled with the aid of MRI.
MRI scanning was done on 12 consecutive patients [ 15 to 48 years] who underwent arthroscopic ACL repair at 3 weeks, 3 months, 6 months and one year after surgery. The tendon defect was not closed, only the peritenon was sutured. The tendon gap and the patellar bone harvest site were evaluated.
Although the patellar tendon defect had decreased by an average of 62% at one year, only 2 persons had healed completely and some had not healed at all. Tendon width and length decreased. The greatest change occurred between 3 and 6 months after surgery thereafter healing showed down.
Jee W-H, Choe B-Y, Kim J-M, et al [Catholic Univ, Seoul, Korea]
The Plica Syndrome : Diagnostic Value of MRI with Arthroscopic Co-relation
J Comput Assist Tomogr 22: 814-818, 1998
This is a study of the efficacy of MRI in diagnosing plica syndrome.
The MR images of 55 patients with arthroscopically confirmed pathologic mediopatellar plicae were compared with those of 100 patients without plicae.
The sensitivity and specificity of axial multiplanar gradient-recalled [MPGR] images for diagnosing plica syndrome were 73% and 83% respectively and for the combination of these images they were 95% and 72% respectively. With the criterion of extension beyond the medial end of the patella on axial MPGR images, the incidence of pathologic medial plica increased.
MRI is a useful non invasive screening tool for diagnosing plica syndrome before arthrography.
Yumoto E, Sanuki T, Hyodo M, et al (Ehime Univ, Japan)
Three-Dimensional Endoscopic Mode for Observation of Laryngeal Structures by Helical Computed Tomography.
Laryngoscope 107: 1530-1537, 1997.
Helical scanning CT was used to produce high quality 3D endoscopic images of larynx. The method has been described. The method used was in 12 patients with normal and affected larynx, either by cancer, nerve palsy and atrophy. This method provided useful diagnositc and therapeutic information in patients with RLN palsy. In cancer patients axial images allowed better assessment of characteristic lesions than CT endoscopic images alone.
This new technology can take 3D data and through obstruction technique, produce an image than appears as the “New” of the larynx through an endoscope. G.R.Holt.
Jouveshomme S, Dautzenberg B, Bakdach H, et al [Hopital Pitie-Salpetriere, Paris: Centre Medico Chirurgical du Val d’Or, St Cloud, France]
Preliminary Results of Collapse Therapy with Plombage for Pulmonary Disease Caused by Multidrug-resistant Mycobacteria
Am J Respir Crit Care Med 157: 1609-1615, 1998
Although excisional surgery is recommended for patients with pulmonary diseases resulting from multidrug-resistant mycobacteria, two thirds of patients are high risk and therefore not eligible.
Patients who had multidrug-resistant strains of mycobacteria and extensive bilateral cavitary disease were treated with collapse therapy.
The cavitary portion of the lungs was collapsed and the intercostal extra periostal space was filled with 5 to 18 polystyrene spheres that were 4 cm in diameter.
Collapse therapy is an effective treatment for high -risk patients with pulmonary disease caused by multidrug-resistant mycobacteria.
Aquino SL, Chiles C, Halford P [Wake Forest Univ, Winston-Salem, NC]
Distinction of Consolidative Bronchioloalveolar Carcinoma From Pneumonia- Do CT Criteria Work?
AJR 171: 359-363, 1998
About 30% of bronchioalveolar carcinomas [BACs] are of the consolidative type. Certain chest CT findings are reportedly helpful in identifying pulmonary consolidation as BAC.
In addition to consolidation, the review focused on features such as nodules and ground-glass opacities; cysts, or cavities within the consolidation.
In the BAC group, all patients had consolidation, more often with a peripheral distribution.
Findings that were present significantly more often in patients with consolidative BAC were coexisting nodules and a peripheral pattern of consoliation.
Consolidative BAC should be suspected in adult patients with normal immunity who had a nonresolving peripheral consolidative pneumonia, particularly when associated nodules are present.
Valji AM, Maziak DE, Shamji FM, et al [Ottawa Civic Hosp, Ont, Canada]
Postoneumonectomy Syndrome: Recognition and Management
Chest 114: 1766-1769, 1998
Postpneumonectomy syndrome [PPS] is caused by extreme shift and rotation of the mediastinum after pneumonectomy. It can produce symptomatic proximal airway obstruction and airway trapping.
Clinical diagnosis of PPS was made with the aid of chest radiographs, 2-dimensional echocardiography, pulmonary function tests, CT scans, and awake fiberoptic bronchoscopy.
After complete mobilization of the mediastinum, anterior pericardiorrhaphy was done before the pericardium was anchored in the parasternal chest wall with suture. A Silastic prothesis filled with saline solution was placed to correct overshifting of the mediastinum.
The diagnosis of PPS should be considered in all patients with progressive dyspnea after pneumonectomy. Repositioning of the mediastinum by means of a prosthesis filled with saline solution and anterior pericardiorrhaphy is a simple procedure and offers immediate and lasting symptomatic relief.
Rubin DA, Kettering JM, Towers JD, et al [Univ of Pittsburgh, Pa; West moreland Regional Hosp, Greensburg, Pa]
MR Imaging of Knees having Isolated and Combined Ligament Injuries
AJR 170: 1207-1213, 1998
MRI is more sensitive than physical examination in detecting meniscal tears in patients with torn ACLs.
The sensitivity of MRI in the diagnosis of ACL tears was 93%, with a specificity of 93% to 96%.
MRI offered a sensitivity of 93% for isolated ACL tears, 83% for ACL tears when both the ACL and posterior cruciate ligament [PCL] were torn, 100% for isolated PCL tears.
The incidence of medial meniscus tears was 49% in knees with all ligaments intact.
MRI scanning continues to be a valuable diagnostic procedure, particularly if the physical examination is difficult or incomplete.
Hamid Mumtaz Steven E. Harms
New Imaging for Breast Diseases
Recent Advances in Surgery, Number 22, Year - 1999, Pg 31
Multiple studies have demonstrated that conventional film or screen mammography enables detection of early clinically occult cancer and the use of screening mammography decreases mortality from breast cancer. About 5-51% of cancers are not visualized at all by mammography. Ultrasonography is accurate in determining tumour size, multifocality and intraductal disease.
Two new imaging modalities, namely magnetic response [MR] imaging and nuclear medicine related imaging techniques have potential future applications.
In MR imaging of the breast, gadolinium chelate is given as a rapid intraveous bolus injection for contrast enhancement.
Malignancy was defined as those lesions that enhanced within 11.5s after the aorta opacified with the contrast media. The development of newer, better targeted, contrast agents that stay within the tumour for a longer period of time will help further advances in implementation of breast MR imaging.
The sensitivity of MR imaging in the diagnosis of breast cancer reported in most studies has varied from 80-100%. Its sensitivity was greater than mammography and ultrasonography. MR imaging missed only 2% of the index tumours as compared with mammography that missed 10% and ultrasonography 15% of the cases. The accuracy of MR imaging in defining the tumour margins may assist in planning the extent of surgical resection required to obtain negative resection margins. MR imaging is more accurate than mammography in depicting tumour involvement of nipple-retroareolar zone and predicting the presence of an extensive intraductal component.
Single-gamma studies, 99m technetium setamibi and 99m Tc tetrafosmin have largely replaced thallium-201 for breast scintigraphy as nuclear Breast imaging techniques.
The high cost currency associated with both imaging modalities precludes their routine use for diagnostic breast imaging.
Daneman A, Lobo E, Alton DJ, et al [Univ of Toronto]
The Value of Sonography, CT and Air Enema for Detection of Complicated Meckel Diverticulum in Children with Nonspecific Clinical Presentation
Opediatr Radiol 28: 928-932, 1998
Complicated Meckel diverticulum [MD] in children does not always manifest as painless rectal bleeding which can create a diagnostic problem.
The inflamed hemorrhagic and inverted intussuscepted MDs have a 9 spectrum of recognizable features on US, CT, and air enema. Some of these features are specific.
Recognizing the features will facilitate the detection of complicated MD in more children who have symptoms in addition to those with painless rectal bleeding.
The presence of sonographic “gut signature” certainly helps in assessing the character of what may be a nonspecific mass of mixed echoes.
Benson JE, Strauch ED [Johns Hopkins Hosp, Baltimore, Md]
Retropsoas Hernia as a Cause of Chronic Abdominal Pain : CT Diagnosis
Pediatr Radiol 28: 312-314, 1998
Mobile bowel or omentum can herniate and sometimes strangulate in patients with congenital or acquired defects in the peritoneal lining of the abdominal wall or mesentery.
Surgery revealed a true peritoneal defect 2.5 cm long along the lateral border of the psoas muscle just superior to the iliac crest, with small bowel herniating through this defect to a depth of 4 cm.
Congenital retropsoas small bowel herniation was found to be the cause of long-standing recurrent abdominal pain. This entity should be considered in the differential diagnosis of abdominal pain, mass, or retroperitoneal gas and fluid. Clinicians also need to be aware of this entity to avoid complications of percutaneous renal interventions.
Pelage J-P, Le Dref O, Mateo J, et al [Hopital Lariboisiere, Paris]
Life-threatening Primary Postpartum Hemorrhage: Treatment with Emergency Selective Arterial Embolization
Radiology 208:359-362, 1998
All patients had intractable hemorrhage that could not be controlled by vaginal packing or uterotonic drugs.
Emergency selective arterial embolization is safe and effective for treating intractable primary postpartum hemorrhage. With arterial embolization, high-risk surgery can be avoided and the patient’s reproductive ability can be maintained.
Despite the seemingly ideal nature of gelfoam as an embolic agent in this setting, the authors substituted polyvinyl alcohol in some patients because of the fear of transmitting Creutzfeldt-Jakob disease with the former.
Thurmond AS, Brandt KR, Gorrill MJ [ Legacy Meridian Park Hosp, Tualatin, Ore: Oregon Health Sciences Univ, Portland; Mayo Clinic, Rochester, Minn]
Tubal Obstruction After Ligation Reversal Surgery : Results of Catheter Recanalization
Radiology 210: 747-750, 1999
For women desiring reversal of sterilization by fallopian ligation, surgery consists of careful resection of the damaged segment of tube and anastomosis.
Tubal occlusion is a common cause of nonconception after ligation reversal surgery.
All underwent transcervical fluoroscopically guided catheter recanalization using standard coaxial technique. Selective salpingography
was done to confirm recanalization.
Fluoroscopically guided catheterization successfully recanalizes 68% of tubal obstruction in women with ligation reversal surgery.
Morgenstern LB, Luna-Gonzales H, Huber JC Jr, et al [ Univ of Texas, Houston]
Worst Headache and Subarachnoid Hemorrhage: Prospective, Modern Computed Tomography and Spinal Fluid Analysis
Ann Emerg Med 32: 297-304, 1998
Although lumbar puncture [LP] may be the best assessment for subarachnoid hemorrhage [SAH], this procedure causes discomfort and is time consuming and costly. The ability of modern head CT to exclude SAH was investigated.
Patients reporting the “worst headache of their lives” should undergo noncontrast head CT. If the CT result is negative, patients should undergo LP with spectrophotometric analysis of the CSF. LP should be recommended because of the potentially devastating consequences of undiagnosed SAH.
It’s important to remember that the relative sensitivity of LP and CT behave differently over time: CT may become negative after 48 hours and LP may not become positive until after 12 hours.
The overall conclusion of this article is that, even with contemporary or “modern” scanners, and LP is still required in the face of a negative CT, when the patient presents with a history of “worst headache of my life” especially when the headache has an abrupt onset.
Bell TV, Fenion HM, Davison BD, et al [Boston Univ]
Unenhanced Helical CT Criteria to Differentiate Distal Uretaral Calculi from Pelvic Phleboliths
Radiology 207:363-367, 1998
A visible central lucency was seen in phleboliths. The “cornet sign” [adjacent eccentric, tapering soft tissue mass corresponding to the non-calcified portion of pelvic vein] was seen in phleboliths. A central lucency or “cornet sign” was NOT seen in any of the calculi. But calculi showed soft tissue rim sign.
Thus calculi could be differentiated from phleboliths by soft tissue rim sign which is due to edema of ureteral wall around calculi.
Spiral i.e. Helical CT has more advantages over orthodox urography in evaluation of urolithiasis. CT is faster and more information is obtained. However, distal calcui are often difficult to differentiate from phleboliths. But the soft tissue rim sign is most sensitive indicator of a calculas.
CCA Nolte Ernsting, A Buker, GB Adam, et al
Gadolinium Enhanced Excretory Magnetic Resonance Urography After Low Dose Diuretic Injection: Comparison with Conventional Excretory Urography.
Radiology 209: 147-157, 1998.
T2 weighted MR urography yields ‘water’ images of the kidney. MRU must be performed with contrast to provide structural and functional information.
MRU was performed after i.v. injection of 5-10mg Furosemide followed by 0.1 mmol of gadopentetate dimeglumine/kg body wt. Urograms were obtained within 5-20 mins after injection of contrast.
The collecting system was well visualized and images were not affected by gas filled intestinal loops or peristalsis.
Compared with conventional excretory urography, bladder and ureter, visualization was significantly better with MRU. Procedure was well tolerated and acquisition time was less than 45 mins.
False positive rates were from 10-15%. MRU does not visualize small caliceal abnormalities as well as conventional urography.
Even with fat suppressed images, magnetic resonance images are of poorer quality to those obtained by conventional urography. In patients with renal failure ionizing radiation and contrast are not required.
CL Siegel, WD Middleton, SA Teffey et al (Washington Univ, St. Louis)
Sonography of the Female Urethra
AJR 170:1269-1274, 1998.
Availability of small calibre, catheter based endoluminal sonographic transducers have enabled a more thorough sonographic evaluation of female urethra.
Sonography can provide important information on location and extent of diverticular neck.
Application of this technology in the general population with an otherwise low incidence of urethral diverticulum and other periurethral disease is probably not warranted at this time.
It may have a role to play in those cases when diverticulum and periurethral disease is suspected but not picked up on VCU (voiding cystourethrogram) or double balloon urethrography.
MA Goldbergm WW Mayo-Smith, et al (Harvard Med. School, Boston)
FDG PET Characterisation of Renal Masses: Preliminary Experience.
Clin. Radiol 52: 510-515, 1997.
Fluorine-18, 2-fluoro-2deoxy-D-glucose positron emission tomography (FDG PET).
It is promising in the assessment of indeterminate renal cysts. A positive result in the appropriate clinical setting obviates the need for cyst aspiration.
Negative findings in conjunction with negative cyst aspiration helps to confirm that the cyst is benign. Seminomas seem to image most intensely with the modality.
FDG PET may find a place in the diagnosis of indeterminate renal masses.
RJ Leveillee, L Pinchuk, GJ Wilson, et al. (Univ of Miami, Fla; Univ of Toronto)
A New Self-Expanding Lined Stent-Graft in the Dog Ureter: Radiological, Gross, Histopathological and Scanning Electron Microscopic Findings:
J Urol 160: 1877-1882, 1998.
Ureteral structures or malignant ureteral obstructions are usually treated with indwelling stents or Nephrostomy tubes. Both these methods need periodic changing.
The wallstent has been used in benign prostatic hypertrophy (BPH) and in the urethra for malignant obstruction.
Epithelial in-growth and hyperplasia that might cause recurrent obstruction have always been problems with this device.
The experimental model showed a lined device has lower tissue reactivity when placed in a normal ureter. Delivery of the device requires a percutaneous Nephrostomy.
AC Gulanikar, PP Daily, NK Kilambi, et al (Univ of Mississipi Jackson)
Prospective Pretransplant Ultrasound Screening in 206 Patients for Acquired Renal Cysts and Renal Cell Carcinoma.
Transplantation 66: 1669-1672, 1998.
The fastest emerging population coming to dialysis comprises patients over 60 yrs of age. The long-term survival of patients in this category is generally poor. Hence there is little enthusiasm for screening all end-stage renal disease patients for acquired renal cystic disease and renal cell carcinoma.
The exception to the rule is patients who are healthy enough to be considered for renal transplantation.
A prevalence of renal cell carcinoma at 3.4% (much higher than the prevalence in the general population) is certainly high enough to warrant routine pretransplant screening. This is especially true in the light of the uncertainties regarding biologic activity of renal cell carcinoma in immunosuppressed hosts.
S.K. Mathur, Z.F. Soonawalla, S.R. Shah, M. Goel and S. Shikare [ Department of Surgery and Gastrointestinal Surgical Services and Department of Nuclear Medicine, King Edward VII Memorial Hospital, Bombay – 400 012, India ]
Role of Biliary Scintiscan in Predicting the Need for Cholangiography
Br. J. of Sur., Volume 87, Number 2, February, 2000, Pg.181-185
Seventy -five patients with symptomatic gallstone disease were studied prospectively regarding the value of a history of jaundice or acute pancreatitis, raised serum bilirubin and serum alkaline phosphatase levels, and visualization of stones or presence of dilated bile ducts on ultrasonography in detecting bile duct calculi. Results of biliary scintiscan were evaluated against a combination of standard criteria. The ‘gold standard’ for evaluation was endoscopic or peroperative cholangiography.
Biliary scintiscan had higher sensitivity and specificity [93 and 94 per cent] than a combination of the standard and modified predictors for biliary calculi [89 and 71 per cent]. A combination of ultrasonography and selective use of scintiscan, in the absence of bile duct dilation only, had highe values [ 96 and 98 per cent].
They conclude that a combination of ultrasonography and billiary scintiscan can accurately predict bile duct calculi and could be used as a guide for selective chlangiography.
T.M.D Hughes and A.J. Spillane [ Sarcoma Unit, Royal Marsden Hospital NHS Trust, Fulham Road, London SW3 6JJ, UK]
Imaging of Soft Tissue Tumours
BRJ Volume 87, No.3, March 2000, Pg.Nos. 259-260
Magnetic resonance imaging [MRI] has become the standard for preoperative assessment of soft tissue masses but a review of the recent literature on the imaging of soft tissue tumours has shown that the best available evidence does not support the current paradigm of MRI superiority over contrast-enhanced computed tomography [CT].
The claim that the introduction of MRI has made limb conserving surgery possible is also false. Limb salvage has, in reality, been made possible through a better understanding of the anatomical relationship amd oncological behaviour of these tumours with respect to neurovascular and proximal limb structures, the expanded role of reconstructive procedures and the expert use of preoperative or postoperative radiotherapy.
Errors in judgement arise particularly when peritumoral oedema is mistaken for tumour infiltration, resulting in overestimation of tumour extent.
The claim that MI is superior for the evaluation of anatomical compartment and individual muscle involvement has bot been substantiated.
The best available evidence is contrary to the commonly accepted wisdom that MRI is superior to CT in the assessment of soft tissue tumours.
Imaging determines the site and extent of the lesion, along with the proximity of nearby structures. Clinical assessment by experienced specialists, appropriate biopsy and multidisciplinary review are together of at least equal importance in the management of these tumours.
Wang PTH, Bonavita JA, DeLone FX Jr, et al [Crozer-Chester Med Ctr, Upland,Pa]
Ultrasonic Assistance in the Diagnosis of Hand Flexor Tendon Injuries
Ann Plast Surg 42: 403-407, 1999
This study examines the contribution of ultrasonography to the diagnosis of flexor tendon injuries.
Eight patients were studied, clinically there was inability to flex the finger. Evaluation was performed using an ATL-HDI-3000 US unit with a high -resolution 5- to -9 MHz hockey stick linear probe. Real-time flexor tendon manipulation was performed to stimulate the patient’s symptoms. These findings were compared with the operative findings.
3 cases of flexor digitorum profundus tendon rupture were diagnosed by USG. These injuries resulted from forceful extension, penetrating injury, delayed rupture 3 weeks after previous repair respectively. In all 3 cases the US findings were confirmed at surgery. In the remaining 5 cases [forceful extension, penetrating trauma, phalangeal fracture and crush injury]. The US showed the tendons to be intact; at operation, in 3 cases these findings were confirmed.
The authors conclude that US is a useful diagnostic tool for clinically equivocal flexor tendon injuries.
Drape J-L, Tardif-Chastenet de Gery S, Silbermann-Hoffman O, et al [ Hopital Cochin, Paris; Hopital Bichat, Paris]
Closed Ruptures of the Flexor Digitorum Tendons: MRI Evaluation
Skeletal Radiol 27: 617-624, 1998
This study evaluates the role of MRI in the diagnosis and management of closed flexor digitorum tendon ruptures.
10 patients [7 male, 3 female mean age 48.5 years] with suspected closed ruptures of FDT underwent preoperative MRI of the hand with T1 weighted spin-echo sequences, 3-D gradient-echo images, and curved reconstructions to examine the FDT. The level of rupture, the gap between the tendon ends and the position of the proximal end of the tendon were then compared between MRI and operative findings.
MRI indicated 12 FDT ruptures, FDP alone 4 cases, FDP +FDS rupture 3 cases, and FDS alone 2 cases, and FDL alone 2 cases. These findings were confirmed at surgery. The level of rupture, the gap between the tendon ends correlated well with operative findings; further, MRI could detect tendinitis in 3 adjacent tendons.
The authors conclude that MRI can accurately identify the level of tendon rupture and the gap between the tendon ends and is useful in the diagnosis and management of tendon ruptures.
Gabl VM, Lener M, Pechlanner S, et al [ Universitatsklinik fur Unfallchirurgie, Innsbruck, Germany; Institut fur Magnetresonanztomographie und Spektroskopie, Innsbruck, Germany]
Closed Traumatic Rupture or Overuse Syndrome of the Flexor Tendon Pulleys? Early Diagnosis by MRI [German]
Handchir Microchir Plast Chir 28: 317-321, 1996
This study examines the efficacy of MRI for the diagnosis of closed injuries to the flexor tendon pulleys.
18 rock climbers with recent injuries were studied. 8 [overuse injuries] were treated conservatively along with [short pulley ruptures]. 2 patients with long pulley ruptures were operated [tendon grafting]. They were followed up for 36 months.
An MRI was done in all cases for diagnosis. Bowstringing or flexion contracture after treatment was not clinically detectable in any patient. All but 1 patient had nearly normal range of movement. Lasting swelling was the only clinical feature of partial instability. MRI was able to detect minor bowstringing and scars in most patients.
They conclude that MRI was useful in detecting the presence and extent of pulley injury.
Failla JM, Jacobson J, van Holsbeeck M [Henry Ford Hosp, Detroit]
Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/Dislocations
J Hand Surg [Am] 24A: 257-266, 1999
This study evaluates the usefulness of ultrasonography in the diagnosis of torn interosseous membrane [10M] in forearm fractures/dislocations.
US was performed transversely on 2 cadaver forearms with intact IOM and again to confirm transection after 10M was transected in 1 forearm. Then US was performed in 2 Galeazzi fracture-dislocations 1 Essex-Lopresti injury were and compared with findings at operation. The authors conclude that US is a useful modality to diagnose and locate a torn IOM allowing primary repair to be performed.
Wallace AL, Haber M, Sesel K, et al [ Prince of Wales Hosp, Sydney, Australia; IIIawarra Private Hosp, Wollongong, Australia]
Ultrasonic Diagnosis of Interosseous Ligament Failure In Radioulnar Dissociation
Injury 30: 59-63, 1999
Complex fractures of the elbow can be difficult to diagnose – thus “radioulnar dissociation is sometimes accompanied by interosseous ligament failure. This study used ultrasonography to make a diagnosis of I0M tear with comminuted radial head fracture. They feel that US imaging to an unexpensive, safe and readily available modality for obtaining images at baseline and throughout the healing process and for detecting occult injury of the interosseous ligament.
Wolf JM, Weiss A-PC [Brown Univ, Providence, RI]
Portable Mini-fluoroscopy Improves Operative Efficiency In Hand Surgery
J Hand Surg [Am] 24A: 182-184, 1999
This study compares the use of traditional radiographic confirmation versus mini-fluoroscopy in a paired, retrospective cohort case study.
30 patients underwent closed reduction or internal fixation of phalangeal shaft fractures or metacarpophalangeal or inter-phalangeal joint fusions. Standard intraoperative and lateral radiographs were used in 15 procedures and portable mini-fluoroscopy in the other 15 procedures.
The minifluoscopy reduced operative time by 55% in phalangeal fractures by 39% in wrist fusion and by 48% in the in-situ 4 corner fusion.
They conclude that mini-fluoroscopy is a safe effective and efficient modality in the tested surgical procedures.
Turgeon TR, MacDermid JC, Roth JH [Univ of Western Ontario, London; St Joseph’s Health Centre, London, Ont]
Reliability of the NK Dexterity Board
J Hand Ther 12: 7-15, 1999
This study evaluates the reliability of the NK dexterity test as a part of a comprehensive computerized hand evaluation system.
37 volunteers [24 women and 13 men] were tested on the NK dexterity board on 2 separate occasions. On each occasion individuals moved small, medium and large objects in 3 separate tests and separately with each hand.
Most complained of arm or forearm fatigue, and had difficulty with threading the medium and large screw-type objects. Intraoccasion intraclass correlation coefficients [ICCs] [n=12; 3 tests x 2 hands x 2 occasions] were fair in half of the comparisons and excellent in the other half. Reliability was better in the dominant hand. ICCs for tests involving small medium objects were fair but for large objects were excellent.
They conclude that although the NK dexterity board has fair-to-excellent reliability, there is a room for improvement. Suggestions made for improving the insrumentation include adding a steel lining to the plastic receptacle of the small steel screw, changing the T-shaped object in the medium sized test from aluminum to steel reducing the length of threading on the large screw object, and establishing a method to lubricate the large screw object.
Nonetheless, this board has several advantages including its ability to test a wide variety of gross and fine movements, a computerized recording system that reduces operative error and normative data in the software for comparison based on age and sex.
Marx RG, Bombardier C, Wright JG [Univ of Toronto]
What do we Know About the Reliability and Validity of Physical Examination Tests Used to Examine the Upper Extremity?
J Hand Surg [Am] 24A: 185-193, 1999
For a physical examination to be useful each test must be reliable and valid. A review was made of the reliability and validity of commonly used physical examination tests for disorders of the upper extremity.
Relevant articles from literature, standard tests and fro consulting experts, were reviewed and analyzed separately from the point of the impairment of function and diagnosis.
The tests for range of motion and strength testing were considered reliable. The tests used to diagnose upper extremity disorders like carpal tunnel syndrome and rotator cuff tendinopathy have varying degrees of validity. Overall, there is sparse evidence regarding the reliability and validity of physical examination for the upper extremities both from the point of diagnosis and impairment of function.
It is therefore recommended that these tests not be used in isolation. It is important that the properties of each test be documented, so clinicians may reliably and accurately examine patients.
Sarhadi NS, Shaw-Dunn J[Univ of Glasgow, Scotland]
Transthecal Digital Nerve Block: An Anatomical Appraisal
J Hand Surg [Br] 23B: 490-493, 1998
This study investigates the anatomical basis of a transthecal digital nerve block for local anesthesia of digits in 60 digits from 40 cadavers.
Methylene blue and latex were injected into cadaveric digits to determine how anesthesia fluid injected into the flexor tendon sheath may spread around the finger.
In digits when 3cc of solution was injected, irrespective of the puncture site, blotchy dye stains were seen on the dorsum of the proximal part of the finger, and the sides of the interphalangeal joint and the metacarpophalangeal joint and both the neurovascular bundles and the flexor tendon sheath were also stained. Dye stains were seen at the wrist when the injections were given at the thumb base and the little finger. Injections in the other fingers did not stain the proximal palm.
If only 0.5cc were injected into the tendon sheath, staining appeared on the dorsum of the digit at its base and around the p.i.p. joint. It also tracked alongside the vessels. The fatty tissue showed linear staining, but no staining of nerves. Deeper staining was seen at the base of the proximal phalanx or in the region of the middle phalanx.
Transthecal injection of 1 ml, resulted in a pool of dye around the neurovascular bundles, in the tissue space enclosed by Cleland’s ligament and Grayson’s ligament right to the tip of the finger.
The authors conclude that injected dye solution escapes from the flexor tendon sheath around the vincular vessels, through the perivascular loose areolar tissue, and spreads alongside the main digital vessels and nerves and their branches.
Lundborg G, Rosen B, Lindberg S [Malmo Univ, Sweden]
Hearing as Substitution for Sensation : A new Principle for Artificial Sensibility
J Hand Surg [Am] 24A: 219-224, 1999
Sense substitution is commonly used among patients with sensory deficits, such as the use of Braille to read by blind people. This study describes an attempt to use hearing as a substitute for lost sensibility.
This study used vibrotactile stimuli to generate sounds as a substitute for hand sensibility. Miniature condenser microphones were attached to the distal, dorsal side of a glove to magnify the friction sound generated. The signal from the microphone was processed by a stereo amplifier which separated signals from different fingers into different channels. These sounds were then fed through earphones to patients with lost hand sensibility [3 had undergone median nerve repair, 1 had an replantation of an amputated forearm, 1 had a myoelectric prosthesis, and 4 had cosmetic prostheses. The patients participated in studies to assess spatial resolution and differentiation between textures.
The spatial resolution of signals allowed patients to differentiate between the various fingers. Friction sounds enabled the patients to identify textures – such as glass, metal, wood and paper.
The findings suggest that hearing may provide a useful substitute for lost hand sensibility.
M. M.Fynes, M. Behan, C.O’Herlihy and P.R. O’Connell [ Department of Surgery and Radiology, Mater Misericordiae Hospital and Department of Obstetrics and Gynecology, National Maternity Hospital, University College Dublin, Dublin, Ireland ]
Anal Vector Volume Analysis Complements Endoanal Ultrasonographic Assessment of Postpartum Anal Sphincter Injury
Br.Jour. of Surg. Volume 87, No.9, September 2000, Pgs. 1209-1214
This study aims to determine the role of anal vector manometry in the assessment of postpartum anal sphincter injury and to determine the most suitable method of anal vector volume analysis for identifying significant external anal sphincter [EAS] injury in an at-risk parous population.
101 women with a history of instrumental or traumatic vaginal delivery were studied by anal ultrasonography and anal vector manometry.
17 women had significant EAS disruption identified by ultrasonography.
Anal vector manometry provided complementary functional information. Anal Vector Symmetry index [AVSI] determined by analysis of mean maximum squeeze pressure, yielded 100 per cent sensitivity for significant EAS disruption with a positive predictive value of 61%.
NH Blevins, BL Carter (Tufts-New England Med Ctr, Boston)
Clinical Forum: Routine Preoperative Imaging in Chronic Ear Surgery,
Am J Otol 19: 527-538, 1998.
Imaging studies, especially CT, can demonstrate the nature and extent of chronic otitis media, which may not be apparent on clinical findings per se. Such findings can affect operative treatment, especially in difficult and/or revision procedures. However, there is a view that routine radiography of the mastoid may suffice in being very helpful in most cases.
TS Karhuketo, HJ Puhakka (Tampere Univ, Findland)
Middle Ear Imaging Via the Eustachian Tube With a Superfine Fiberoptic Videomicroendoscope.
ORL J Otorhinolaryngol Relat Spec. 60: 30-34, 1998.
With a fibreoptic videomicroendoscope inserted through the Eustachian tube, 56% of predetermined anatomical objects in the middle ear were visualized.
However, one may find obstructive sites or mucosal folds.
T Johkoh, H Itoh, NL Muller, et al (Osaka Univ, Japan; Univ of British Columbia, Vancouver, Canada; Kyoto Univ, Japan et al)
Crazy-paving Appearance at Thin-Section CT: Spectrum of Disease and Pathologic Findings.
Radiology 211: 155-160, 1999.
The crazy-paving pattern noted on some thin-section CT scans is a fine reticular pattern superimposed on a background of ground-glass opacity. The diseases that are associated with this pattern and the pathologic findings that cause this appearance were identified.