螺旋CT在踝关节及跗骨骨折中的应用价值

目的探讨螺旋CT在踝关节及跗骨骨折中的应用价值。方法收集分析43例踝关节及跗骨骨折,所有病例均行普通x线摄影和螺旋CT薄层扫描,35例螺旋CT扫描后选择性应用表面遮盖显示（SSD）和多平面重组（MPR）等图像后处理技术进行图像重建。结果在43例骨折病例中,28例（65．1％）普通x线检查报告为阳性的病例经螺旋CT扫描又发现其他部位骨折,15例（34．9％）普通x线检查报告为阴性的病例经螺旋CT确诊为阳性;螺旋CT上骨折线表现为长度、宽度、走行及数量不同的线状低密度影,对粉碎性和撕脱性骨折病例再行SSD和MPR图像重建,进一步明确骨折线的空间走向和碎骨片的形状、大小及空间位置。结论螺旋CT薄层扫描结合图像后处理技术,在踝关节及跗骨骨折中有非常重要的应用价值。     

The ultrasonographic deep sulcus sign in traumatic pneumothorax

A series of 186 patients with blunt chest trauma was studied with transthoracic ultrasonography to diagnose pneumothorax and to evaluate its size and location. The results were compared with bedside chest radiography and spiral CT scan. The prevalence of pneumothorax on CT scan was 56/186 (30.1%). Pneumothorax was proven on radiography in 30/56 cases without false positive results: "radiographic deep sulcus sign" was evident in 3/29 cases, 26/29 cases being occult. The ultrasound study demonstrated the presence of pneumothorax in 55/56 patients: one occult pneumothorax was missed and no false positive results were observed. The CT scan differed of +/-2.3 cm (range 1-5 cm) from the US study in evaluating size and location of pneumothorax. In conclusion, ultrasound study may detect occult pneumothorax undiagnosed by standard plain radiography. It reflects accurately the extent of pneumothorax if compared with CT scan, outlining the "ultrasonographic deep sulcus sign" on anterior chest wall.     

Sonographic detection of occult fractures in the foot and ankle.

PURPOSE: The purpose of this retrospective study was to determine whether high-resolution sonography can aid in the diagnosis of radiographically occult fractures in the foot and ankle. METHODS: High-resolution sonography with a 10-MHz linear-array transducer was performed in 268 patients with foot and ankle injuries whose initial plain x-ray films were negative for fracture. RESULTS: Twenty-four patients had occult fractures demonstrated by sonography. On sonography, the occult fractures appeared as a discontinuity of cortex echogenicity. The fractures were found at the calcaneus (n = 8), metatarsus (n = 6), talus (n = 3), navicular bone (n = 3), cuboid bone (n = 2), cuneiform bone (n = 1), and lateral malleolus (n = 1). Review of the patients' radiographs revealed tiny fractures at the sonographically identified locations in 2 patients. The first 5 patients underwent bone scans, which confirmed the presence of the fractures. The first 11 patients received follow-up sonographic examination 6 weeks after diagnosis; in all 11, an echogenic line over the previous fracture site, presumably representing callus formation, was noted. CONCLUSIONS: Sonography-a readily available, noninvasive imaging technique-can provide important information about soft tissue injuries and cortical discontinuities in the foot and ankle area. Using this procedure, occult fractures can be identified and delineated, and costly procedures such as MRI can be avoided.     

螺旋CT二维重建技术在三踝骨折治疗中的应用

目的 探讨螺旋CT扫描二维重建技术在三踝骨折治疗中的作用. 方法 2005年1月至2006年1月浦南医院收治的22例三踝骨折患者,按Lauge-hansen分型,13例为旋后-外旋Ⅳ度,6例为旋前-外旋Ⅳ度,3例为旋前-外展Ⅲ度.对患者术前和术后的X线片与螺旋CT二维重建的检查结果 进行比较,对踝关节术后主观功能评分和客观功能评分与影像学评价之间的关系进行分析. 结果 术前X线片漏诊5例后踝骨折经螺旋CT扫描及二维重建技术确诊;随访时X线片显示关节面未完全复位1例,关节面完全复位的21例中,螺旋CT扫描及二维重建技术发现其中6例仍存在轻度关节面不平,关节面完全复位患者与关节面残留移位患者的主观功能评分存在显著性差异. 结论 螺旋CT二维重建技术能更全面、更准确地提供踝关节骨折的信息,有利于术前诊断、指导手术和疗效评估.     

Ultrasound-assisted triage of ankle trauma can decrease the need for radiographic imaging

BackgroundAn ankle sprain is a common injury, and patients are usually examined with plain radiographs to rule out a fracture despite the fact that only a small minority actually have one.PurposeTo investigate if ultrasound (US)-guided triage can decrease the need for radiographic imaging in patients with ankle trauma.HypothesisOrthopedic surgeons can use point-of-care US with limited training to triage ankle trauma that requires standard radiographs.MethodsSeven junior orthopedic surgeons underwent a 30-minute standardized training session using a basic US musculoskeletal examination designed to exclude ankle fractures.One-hundred twenty-two patients with ankle trauma were included at the emergency department and underwent clinical investigation, including examination according to the Ottawa ankle rules as well as US and standard ankle radiographs. In this study group, radiographs identified 23 significant fractures. Ultrasound-guided triage could not exclude a fracture in 37 patients. All of the 23 fractures seen on radiographs were among the 37 patients where US could not rule out a fracture. Ottawa ankle rules managed to exclude the need for radiographs in 28 of the 122 patients, whereas 85 who underwent the US-guided triage could have avoided a radiograph. Avulsion fractures at the tip of the fibula were not considered significant.ConclusionThis study demonstrates that with limited standardized training a junior, an orthopedic surgeon is able to use US-guided triage during the primary examination at the emergency department to exclude at least significant ankle fractures. This practice could decrease the need for radiographic imaging, avoiding a mandatory radiographic investigation in many patients with ankle trauma. It would also make it possible to treat many patients with ankle trauma more rapidly and to reduce costs and radiation exposure.     

Ultrasonographic examination for inversion ankle sprains associated with osseous injuries

OBJECTIVE: The study attempted to evaluate the value of ultrasonography in determining the therapeutic strategy for patients with osseous injuries caused by ankle sprains. DESIGN: A 10-MHz compact linear-array ultrasound transducer was used to assess patients with inversion ankle sprains. Eleven female and 12 male patients who had fractures detected by sonograms were included in the study. All 23 patients underwent radiographic examination for identification of fractures. Bone scintigraphy was performed for those who had negative x-ray findings. RESULTS: Eighteen patients had distal fibular tip fractures, three patients had the fifth metatarsal base fractures, one patient had a talar neck fracture, and one patient had a navicular fracture. These fractures were all detected by ultrasonography and then proved even by radiography or by bone scans. All the 23 patients had anterior talofibular ligament injuries. Among these patients, 11 had anterior ankle-joint recess effusion, and two had additional anterioinferior tibiofibular ligament injuries. Six weeks of immobilization with the ankle fracture brace was prescribed for all the patients after the identification of fractures. Their ankle pain symptoms soon improved. CONCLUSIONS: Ultrasonography is valuable in evaluating tiny foot and ankle fractures and coexistent soft tissue injuries. It can guide the treatment for patients with osseous injuries caused by ankle sprains.     

Validation of the Ottawa ankle rules in children.

OBJECTIVE: To assess whether the Ottawa ankle rules can be used to accurately predict which children with ankle and midfoot injuries need radiography. METHODS: Prospective study with historical control group of all children aged 1-15 years presenting to Sheffield Children's Hospital accident and emergency department with blunt ankle and/or midfoot injuries during two five month periods before and after implementation of the Ottawa ankle rules. RESULTS: In the study group 432 out of 761 (56.76%) patients received radiography compared with 500 out of 782 (63.93%) in the control group. This was a statistically significant reduction in radiography rate of 7.2% (95% confidence interval 2.3% to 12.1%, p <0.01). The sensitivity of the Ottawa ankle rules was 98.3% and the specificity 46.9%. There was no increase in the number of missed fractures (one in each group). CONCLUSION: The Ottawa ankle rules can be applied in children to determine the need for radiography in ankle and midfoot injuries. Their implementation leads to a reduction in the radiography rate without leading to an increase in the number of missed fractures.     

Imaging of the atlas (C1) and axis (C2)

In imaging the atlantoaxial region in injured patients, the initial modality is plain radiography. The lateral C-spine as well as the open-mouth view are essential in this regard. On these views, it is not only important to examine the bony contour but also to look for indirect signs of injury such as prevertebral soft-tissue swelling, air in the prevertebral space, an increased width of the anterior atlantodental interval, and overriding of the C1-C2 joint on one side (the so-called wink sign of atlantoaxial rotatory subluxation). In patients in whom there is a high index of suspicion for occult trauma, but without fractures suggested or adequately visualized on routine films, or in those with severe cranial trauma, further studies should be pursued. CT scan is the modality of choice in optimally imaging the bony contours of the axis and atlas. It has limitations in visualizing transversely oriented fractures such as high dens fractures, transverse fractures of the facet joints (although widening of the facet joint is an indirect indication of facet fracture), or transverse arch fractures. Plain tomography may better demonstrate such transverse fractures but has several disadvantages. Plain tomography is often not as readily available as CT; it requires that the patient be placed in lateral decubitus position to obtain lateral tomograms, which may be contraindicated in such clinical circumstances; and it is not as easy to appreciate three-dimensional relationships on plain tomography as it is on CT. CT clearly defines the location of displaced bone fragments in relationship to the spinal canal as well as often demonstrating disc injuries. Ligamentous injury, though potentially visualized directly on MR imaging, is more commonly addressed with flexion-extension films. Flexion-extension studies should, obviously, be performed only in awake, oriented patients who are without neurologic deficit, and the studies should be done with close physician supervision and stopped at the first onset of pain. MR imaging may be helpful in demonstrating soft-tissue injuries such as hemorrhage, disc herniation, nerve root impingement, and direct spinal cord damage.     

Validation of the Ottawa ankle rules in children.

OBJECTIVE: To assess whether the Ottawa ankle rules can be used to accurately predict which children with ankle and midfoot injuries need radiography. METHODS: Prospective study with historical control group of all children aged 1-15 years presenting to Sheffield Children's Hospital accident and emergency department with blunt ankle and/or midfoot injuries during two five month periods before and after implementation of the Ottawa ankle rules. RESULTS: In the study group 432 out of 761 (56.76%) patients received radiography compared with 500 out of 782 (63.93%) in the control group. This was a statistically significant reduction in radiography rate of 7.2% (95% confidence interval 2.3% to 12.1%, p <0.01). The sensitivity of the Ottawa ankle rules was 98.3% and the specificity 46.9%. There was no increase in the number of missed fractures (one in each group). CONCLUSION: The Ottawa ankle rules can be applied in children to determine the need for radiography in ankle and midfoot injuries. Their implementation leads to a reduction in the radiography rate without leading to an increase in the number of missed fractures.     

踝关节隐匿性损伤的MRI表现

目的探讨踝关节隐匿性骨折 MRI表现.方法回顾性分析 17例有明确外伤史, X线表现为阴性、MRI表现阳性的病例.使用 Siemens vision- plus 1.5T超导高场 MRI系统成像.常规 SE序列 T1W成像( TR/TE=700/20)、FSE序列 WI( TR/TE=4700/100)和 T2WI脂肪抑制( FS)序列.结果 17例有 9例表现关节软骨不规则缺失; 7例有软骨下骨小梁骨折; 13例患者共有 16处骨髓片状异常信号, 10处为 T1低信号 T2高信号, 6处为 T1低信号 T2混杂信号,脂肪抑制序列表现为明显高或混杂偏高信号;其中 4例伴有关节腔积液、1例有踝关节外侧韧带损伤.结论 MRI是发现踝关节隐匿性损伤的有效检查技术,表现包括关节表面软骨缺失、软骨下皮质骨骨折、皮质下松质骨骨小梁骨折以及骨松质内不规则出血或水肿.     

Magnetic resonance imaging identifies occult hip fractures missed by 64-slice computed tomography

Background

Citing the enhanced resolution of 64-slice computed tomography (CT), some clinicians now use CT instead of magnetic resonance imaging (MRI) to detect occult hip fracture.

Objective

Our objective was to determine the incidence of occult hip fractures missed by 64-slice CT but detected by MRI.

Methods

We reviewed the medical records and radiology reports of patients over age 60 years with a hip fracture (acetabular, intertrochanteric, trochanteric, femoral neck, and femoral head) during a 3-year period, January 1, 2007 through December 31, 2009. We also reviewed all hip CT and MRI scans ordered during that period. Occult fractures were those visualized on CT or MRI but with negative plain films. We compared CT and MRI findings, and calculated percentages and 95% confidence intervals (CIs).

Results

Of 235 hip fractures, 211 were visible on initial plain films (90%, 95% CI 85–93%) and 24 (10%, 95% CI 6–15%) were occult. Eighteen occult fractures (7.6%, 95% CI 4.6–11.8%) were identified by CT (MRI not done), one (0.4%, 95% CI 0–2%) by MRI (CT not done), one (0.4%, 95% CI 0–2%) by both CT and MRI, and 4 patients (1.7%, 95% CI 0.5–4.3%) had a positive MRI but negative CT scan.

Conclusion

Although 64-slice CT detected the majority of occult fractures, it missed four (2%) significant fractures detected by MRI. CT scan is helpful in the diagnosis of occult hip fracture, but one should not completely exclude the diagnosis based on a negative 64-slice CT scan in a patient with persistent, localized hip pain who cannot bear weight.     

16层螺旋CT三维重建技术在肋骨隐匿性骨折中的诊断价值

目的探讨16层螺旋CT三维重建技术在肋骨隐匿性骨折检查中的诊断价值。方法利用PHILIPS公司16层螺旋CT对1 000例胸部外伤患者进行扫描检查,对原始数据做薄层图像重建并传输至工作站,然后进行图像三维重建。包括容积再现（VR）、最大密度投影（MIP）、表面遮盖显示（SSD）等图像重建方法,将不全或无错位骨折定为隐匿性骨折。观察分析肋骨和肋软骨骨折情况,及其周围解剖结构的病变。结果 1 000例中,170例诊断为单发或多发肋骨隐匿性骨折。肋骨骨折总数为195根。CT轴位扫描显示肋骨骨折184根,检出率为94.4%。三维容积重建图像后显示肋骨骨折193根,检出率为99.0%。其中2根肋骨骨折CT轴位扫描显示而三维重建未能显示,11根肋骨（肋软骨）骨折三维重建显示而CT轴位扫描未显示。结论利用多排螺旋CT图像重建技术,对诊断肋骨隐匿骨折的准确性要优于常规CT轴位扫描,为临床诊治肋骨骨折提供重要诊断依据。     

MSCT薄层图像在隐匿性肋骨骨折中的诊断价值

目的探讨MSCT薄层图像及冠状位重建在隐匿性肋骨骨折的诊断价值。方法回顾性分析45例钝性外伤患者肋骨骨折X线阴性的CT薄层图像及冠状位重建,记录肋骨骨折的部位、形态、数目;所有患者均于2⁴周复查,并以患者的随访图像为诊断肋骨骨折的标准,比较MSCT薄层图像、薄层联合冠状位重建在隐匿性肋骨骨折中的诊断准确性。结果 CT随访图像确诊肋骨骨折63根,其中薄层图像检出57根,薄层图像联合冠状位重建检出63根,两者对比有统计学意义(χ2=2.04,P=0.031)。骨折位于前弓31根,腋部17根,后肋15根。肋骨完全骨折25根;肋骨不完全骨折38根(骨密度增高6根,骨皮质皱褶19根,骨皮质翘起13根)。X线阴性肋骨骨折主要发生在前弓,最主要的类型是骨皮质皱褶。结论 MSCT薄层图像能很好地显示隐匿性骨折的类型、部位及数目,联合冠状位重建能提高肋骨骨折的诊断准确性。     

Unsuspected upper cervical spine fractures associated with significant head trauma: role of CT

Several recent studies report the sensitivity of computed tomography (CT) to be far greater than that of traditional plain film radiographic studies for evaluation of cervical spine fractures and spinal cord pathology. Nevertheless, plain films continue to be the standard screening examination. CT is used only if fractures are demonstrated or suspected on plain film survey. Recently, three patients with significant head and neck trauma (all three patients had intracranial hemorrhage) had cervical spine evaluation by computed tomography and standard plain film views. CT demonstrated significant C1-C2 fractures, while plain films were completely normal in all three cases. Prospectively studying the next 50 patients with significant head trauma, we added a few more slices to the routine head scan protocol to cover the first three cervical vertebrae. This added very little time or cost to the procedure. The additional CT images demonstrated four upper cervical fractures that could not be seen on plain films, even in retrospect. Our findings suggest that routine inclusion of the upper cervical spine with head CT is appropriate in the evaluation of patients with significant head trauma as defined by intracranial hemorrhage or skull fracture.     

Association of thoracic cage fractures and pericardial effusion in blunt trauma

BackgroundSeveral case reports suggest that penetrating thoracic cage fractures are an important cause for hemopericardium and cardiac tamponade following blunt trauma. However, the prevalence of this mechanism of injury is not fully known, and considering this association may provide a better understanding of the utility of cardiac component of the FAST (Focused Assessment with Sonography for Trauma).ObjectiveTo determine the association of thoracic cage fractures and pericardial effusion in patients with blunt trauma.MethodsWe performed a retrospective, multicenter cohort study using the Trauma Quality Improvement Program (TQIP) database (2015–2017) of adults ≥18 years of age whose mechanism of injury was either a fall or motor vehicle accident. Thoracic cage fractures were defined as any rib or sternum fracture. The primary outcome was the presence of pericardial effusion. Confounding variables were accounted for using multivariable logistic regression.ResultsWe included 1,673,704 patients in the study; 226,896 (14%) patients had at least one thoracic cage fracture. A pericardial effusion was present in 4923 (0.3%) patients. When a thoracic cage fracture was present, the odds of having a pericardial effusion was significantly higher (adjusted Odds Ratio [aOR] 6.5 [95% CI: 6.1–7.0]). Patients with left and right-sided rib fractures had similar odds of a pericardial effusion (aOR 1.2 [95% CI 1.04–1.4]). Sternal fractures carried the highest odds of having a pericardial effusion (aOR 11.1 [9.9–12.3]).ConclusionThoracic cage fractures secondary to blunt trauma represent a significant independent risk factor for the development of a pericardial effusion. Our findings lend support for the mechanism of bony injuries causing penetrating cardiac trauma. Given these findings, and the fact that many thoracic cage fractures are detected after the initial evaluation, we support maintaining the cardiac view in the FAST examination for all blunt trauma patients.     

Sonographic diagnosis of a radiographically occult displaced fracture of a costal cartilage

We report the case of a 22‐year‐old athlete who sustained a blunt thoracic trauma to the right chest causing a costal cartilage fracture. Plain radiographs revealed no abnormalities while sonographic (US) examination performed a week later because of persistent pain led to the diagnosis of a displaced fracture of the right tenth costal cartilage. A follow‐up US examination confirmed the healing of the fracture and allowed the patient to return to competitive sport activity. We recommend the use of US in patients with persisting pain after thoracic trauma with negative plain radiographs of the ribs to rule out radiographically occult costal cartilage fractures. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45 :605–607, 2017     

Double take--fracture fishing in accident and emergency practice.

OBJECTIVE: To investigate conditions where, after initially negative plain x rays following trauma, there subsequently proves to be fracture, and to explore ways in which the management might be improved. DESIGN: A 16 month prospective study. Patient details were collected from accident and emergency (A&E) review clinics and returns, A&E ward admissions, correspondence from other services, and discussions at a weekly clinicoradiological conference. The inclusion criteria comprised A&E trauma patients with normal initial plain x rays and proven fractures on subsequent imaging for the same patient event. SETTING: A large A&E department seeing 65,000 new attendances per annum with full back up services. RESULTS: 55 cases were identified: 41 fractures were identified on subsequent plain x ray, six on bone scan, six on CAT scan, and two on MRI scan. The commonest regions involved were the wrist, pelvis/hip, ankle/foot, and leg. Follow up had not been arranged at the initial attendance in 17 instances and between two and 135 days were required for definitive fracture recognition. All but nine patients required alteration in treatment because of fracture detection. CONCLUSIONS: Clinical suspicion of fracture at initial A&E attendance should prompt organised follow up even in the face of normal plain x rays. Consideration should be given to alternative imaging techniques which may have a higher resolution than plain x rays. Close corroboration between A&E and radiology departments has benefits in patient care in this group of patients and may lead to a reduction in functional disability and litigation.     

MR imaging of ankle inversion injuries

Ankle inversions are common in the general population and in athletes. Multiple concurrent injuries are a common result of an ankle-inversion injury. Syndesmosis injury, lateral ankle ligament tears, peroneal retinaculum or tendon injury, osteochondral lesion, or fracture may occur. Chronic pain or instability may result from one or more of these injuries. MR imaging provides superior soft tissue resolution, high sensitivity for occult fractures, and the ability to image the articular cartilage and ankle ligaments directly. This article discusses the MR imaging evaluation of acute and chronic ankle inversion injuries.     

肾破裂出血的CT影像分析（附36例报告）

评价肾出血的CT表现及诊断价值。方法：36例病人中，肾创伤出血28例，25例平扫，3例平扫加增强，发现肾钝性创伤25例、肾穿刺后出血3例；肾肿瘤出血8例，均行平扫，其中肾细胞癌5例，错构瘤3例。结果 36例肾出血CT影像提示为：肾内出血，肾包膜下血肿、肾周血肿及伴风膜囊血肿等。结论 CT检查能准确估计肾出血的原因、程度、范围并能发现其它合并症，为临床选择治疗方案提供重要依据。     

The value of protocol-driven CT scanning in stab wounds to the head

A prospective study involving 179 patients with cranial and orbital stab wounds was undertaken to evaluate the incidence and relationship of clinical findings, radiographs, and computed tomography (CT) findings and treatment decision. Indications for a CT scanning of the head are a of loss of consciousness, convulsions, any neurological deficit, palpable or visible fracture on the skull X-ray film after an attack with a sharp instrument, presence of an impaling weapon. A CT scan and plain radiography were performed in 179 patients. There were pathological CT findings in 128 patients (71.51%). In contrast only 35/179 (19.5%) X-ray films were positive; 11 (6.15%) patients had a palpable fracture. Approximately 80% of all cranial injuries would remain undetected if the diagnosis would be based on a visible fracture. Fifty percent of patients had an admission GCS of 15/15. The importance of a CT scan and the limited benefit of plain radiography alone in stab injuries to the head is discussed.