Ankle tenography: a key to unexplained symptomatology. Part I: Normal tenographic anatomy

Fifty cadaver ankles were examined with ankle tenography. The normal tenographic appearance of the peroneus longus and brevis, posterior tibial, flexor digitorum longus, flexor hallucis longus, anterior tibialis, extensor hallucis longus, and extensor digitorum longus tendons and sheaths are described and illustrated for clinical reference. The baseline measurements and demonstration of the normal radiographic appearance of these tendons should assist in the evaluation of hindfoot foot disability and ankle pain.     

Roentgenographic anatomy of the tendon sheaths of the hand and wrist: tenography.

The radiographic anatomy of the tendon sheaths of the hand and wrist is described. Contrast evaluation, tenography, of these synovial-lined channels utilizing 10 cadaver limbs was accomplished outlining their relationship to adjacent osseous and articular structures. The technique is simple and provides the radiologist with further understanding of the pattern and distribution of roentgenologic alterations accompanying septic and granulomatous processes of the hand and wrist including "horeshoe abscesses" of the palm, osteomyelitis, pyarthrosis, and rheumatoid tenosynovitis. Tenography should be added to the radiologist's ever-increasing armamentarium.     

Magnetic resonance imaging of tendon and ligament abnormalities: Part II. Pelvis and lower extremities

Magnetic resonance imaging (MRI) has provided an ideal means, unmatched by other preexisting modalities, of examining musculoskeletal abnormalities, particularly those involving tendons and ligaments in the lower extremities. Lack of motion artifact, convenience of application of surface coil, and absence of overlying structures have made the lower extremities ideally suited to MRI. In addition, the abundance of adjacent adipose tissue provides a superb contrast background. Although evaluation of trauma remains the most common reason for MRI examination, many other conditions may also affect tendons and ligaments. As in other soft-tissue, chondral, and osteochondral lesions, MRI provides exquisite details of abnormalities in these structures. Part II of this review systematically reviews the abnormalities of tendons and ligaments in the pelvis and lower extremities.     

Diagnosis and treatment of chronic tendon disorders in sports

Sports and physical activity are becoming more important and more emphasized in the lives of the average person as the health benefits of maintaining an active lifestyle are recognized. In the past most people were primarily active in sports during their time in school. The trend is for more people to continue vigorous activity through middle age and beyond. In addition, as high level athletes continue to reach higher levels of performance more amateur athletes attempt to reach similar levels of intensity, which they may not be able to handle with their level or method of training. This has led to an increase in overuse injuries and chronic tendon injuries. It has been estimated that overuse type injuries account for 30–50% of sports injuries (1).     

Pancreas. Part II: Tumors

Adenocarcinoma is the most common malignant pancreatic tumor, affecting the head in 60-70% of cases. By the time of diagnosis, approximately 80% of tumors are unresectable. Helical CT is very effective in detection and staging of adenocarcinoma, with a sensitivity of 76-92% for detection and an accuracy of 80-90% for staging, but it has limitations in the detection of small cancers (< or =2 cm). Multidetector CT (MDCT) has brought substantial improvements with its inherent 3D imaging capability. Mangafodipir-enhanced MRI is a problem-solving tool in the depiction of small cancers following an equivocal CT imaging result. Gadolinium-enhanced 3D gradient-echo MRI is helpful in the assessment of vascular invasion of cancer and in determining the etiology of cystic lesions. Serous cystadenoma is benign, has a lobulated contour and contains innumerable small cysts of 0.1-2 cm in diameter. Mucinous cystic neoplasms are unilocular or multilocular (fewer than six cysts), and the cyst diameter exceeds 2 cm. The presence of solid nodular components should alert the radiologist to suspect cystadenocarcinoma. Neuroendocrine tumors are mostly hypervascular. Diagnosis of insulinoma is a challenge: they are <2 cm in 90% of cases and mostly hypervascular at CT or MRI. A combination of contrast-enhanced MDCT, MRI, endosonography, and/or somatostatin receptor scintigraphy is used to detect these small tumors. This review summarizes the imaging features of the most common pancreatic tumors and discusses the limitations of CT, MRI and endosonography.     

Anterior cruciate ligament reconstruction using quadriceps patellar tendon graft. Part II. A specific sport review

Eighty-three patients, from a 10 year follow-up study, who underwent ACL reconstruction with a quadriceps patellar tendon graft were reviewed. A questionnaire qualifying their sports performance in 20 possible sports compared their preinjury status to postinjury and postreconstructive surgery. Successful and unsuccessful patients, as determined by our previous investigation, were likewise compared. Sports performance, regardless of the sport or level of competition, decreased substantially postinjury and then rose significantly to near but not equal to patient preinjury status. The most strenuous sports dipped to the lowest performance level after injury and returned with a correspondingly more modest gain after the reconstruction. Not surprisingly, successful patients had a more impressive return in performance than unsuccessful patients, mirroring their clinical grading. Of those deemed unsatisfactory (N = 20), graft failures were no worse off in performance rating than those that were classified as unsatisfactory because of persistent symptoms.     

Ankle fractures: Understanding the mechanism of injury is the key to analyzing the radiographs

Injuries to the ankle joint are common. Complete ligament ruptures and fractures of the malleoli and adjacent bones can affect the stability of the ankle joint. If fractures or ligament injuries are present on both sides of the joint, the ankle will usually be unstable. On the other hand, injuries confined to one side of the joint will usually be stable. Unstable ankle joints require operative fixation, whereas stable ankles do well with conservative treatment. Specific ligament injuries precede several fractures. Recognition of the various patterns of injury permits reliable prediction of these ligament injuries. Therefore, it is important for radiologists and others who interpret trauma radiographs to understand the common mechanisms of injury and to recognize these patterns. Correct classification of the injury mechanism should lead to prompt, appropriate diagnosis and treatment and should decrease long-term morbidity.     

The fixation strength of six hamstring tendon graft fixation devices in anterior cruciate ligament reconstruction. Part II: tibial site

BACKGROUND: Tibial fixation is more problematic than femoral fixation in anterior cruciate ligament reconstruction. HYPOTHESIS: There is no difference in initial fixation strength among hamstring tendon graft tibial fixation devices. STUDY DESIGN: Randomized experimental study. METHODS: Each of six devices used to fix 120 quadrupled human semitendinosus-gracilis tendon grafts into porcine tibiae was tested 10 times with a single-cycle load-to-failure test and 10 times with a 1500-cycle loading test. Specimens surviving cyclic loading were subjected to a single-cycle load-to-failure test. RESULTS: Intrafix (1332 N) was the strongest in the single-cycle load-to-failure test, followed by WasherLoc (975 N), tandem spiked washer (769 N), SmartScrew ACL (665 N), BioScrew (612 N), and SoftSilk (471 N). After cyclic-loading tests, Intrafix showed the lowest residual displacement (1.5 mm) and was also strongest (1309 N) in the single-cycle load-to-failure test after the cyclic-loading test, followed by WasherLoc (3.2 mm; 917 N). CONCLUSION: The Intrafix provided clearly superior strength in the fixation of hamstring tendon grafts to the tibial drill hole. CLINICAL RELEVANCE: Some caution may be warranted when using the implants that showed increased residual displacement, especially if aggressive rehabilitation is to be used. Preconditioning of the hamstring tendon graft-implant complex before tibial fixation is needed.     

Principles of rehabilitation after chronic tendon injuries.

This article describes a framework for the evaluation, diagnosis, and management of tendon injuries that result from repetitive microtrauma overload. These injuries are commonly called tendinitis injuries, but are more often degenerative lesions. The initial management of acute tendon injuries with rupture is usually quite different than that of chronic injuries, but the functional rehabilitation of the acute injuries can follow the same framework.     

Ultrasound of tendon tears. Part 1: general considerations and upper extremity

The role of ultrasound (US) in assessing musculoskeletal disorders is persistently increasing because of its low cost, readiness, noninvasiveness, and possibility of allowing a dynamic examination. Secondary to increased sport practice, tendon tears are more frequently observed in daily medical practice. They deserve early diagnosis to allow proper treatment that can limit functional impairment. The aim of this review article is twofold: to illustrate the US appearance of normal tendons and to describe the US findings of the most common tendon tears.     

AHRA survey. Staff utilization: Part II

Part II of this AHRA membership survey reports on information relating to staff utilization in computed tomography, ultrasound and magnetic resonance. The average volume of procedures per full-time-equivalent staff is provided for technologists, clerical staff and physicians. Part III, to be published in the fall issue, will provide reports on radiation therapy and nuclear medicine.     

Croatian rugby project. Part II: injuries

BACKGROUND: Studies of rugby injuries in countries where rugby is not popular are rare. The aim of the study was to analyze the epidemiology and other characteristics of injuries in the first Croatian-Slovenian rugby league (CSRL) and the influence of anthropometric characteristics, body composition and constitution on the epidemiology of injuries. METHODS: Eleven anthropometric measures for the assessment of anthropometric characteristics, body composition and constitution were obtained in a sample of 111 voluntarily participating rugby players from the CSRL in the middle of the season 1996/97. After the season a questionnaire about injuries sustained in the past season was retrospectively filled up by 106 players who finished the first part of the study. Injuries were classified according to Garraway and Macleod and the 9th revision of the International Classification of Diseases. RESULTS: The incidence of injuries was 1.24 per 1000 hours of rugby training and 28.22 per 1000 hours of playing in matches. Low club position in rugby division (statistically significant, p<0.05), age from 25 to 34 years, forwards position in a team, being tackled, and beginning of autumn or spring season were identified as risk factors for injuries. The most frequent sites of injury were legs. The most frequent injuries were dislocations, strains and sprains of ankle and foot. CONCLUSIONS: The incidence of injuries in matches was more than two times higher than in more developed Scottish rugby, statistically positively correlating with the team position in division. There are no statistically significant differences in anthropometric characteristics, body composition and constitution of injured and uninjured players.     

Ultrasound appearance of tendon tears. Part 2: lower extremity and myotendinous tears

Traumatic tears of the musculotendinous complex at the lower limb are common in clinical practice but can be difficult to detect and to evaluate because of swelling and pain that can limit proper physical examination. They can affect sedentary subjects or active sports participants involved in amateur or professional activities. In the first group tendons are more commonly affected, while myotendinous tears are common in sports players. The aims of this review article are to review the aetiology and pathomechanism of the most common ruptures affecting the tendons and the main myotendinous junctions of the lower extremity and to describe their ultrasound findings as well as to correlate ultrasound appearance with that of the other imaging modalities. Part 1 of the article (General considerations and upper extremity) can be found at .     

Flow determination using computed tomography: application to aortic dissection. Part II

Dynamic CT is not only useful in imaging an aortic dissection but may provide additional information concerning the hemodynamic significance of differing flow patterns in the false channel compared with the true channel. Once validated, the computed tomographic (CT) method of flow determination (See Part I) was applied to an experimental animal model with a surgically created aortic dissection. Good correlation was obtained for the flow estimates of cardiac output derived for the true and false channel (r = .82). The shapes of the curves, however, were distinct, reflecting different flow patterns for the true and false channels. Curve parameters, such as peak CT number (P = .0001), variance (P = .006), and, in particular, the number of mixers (a parameter used to quantify the degree of mixing) (P = .0001), demonstrated significant differences between the two channels of the dissection. The curve parameters derived can therefore be used to differentiate the true and false channels and may then predict the long-term outcome of the false channel, and the aortic branches derived from it.     

Repair of chronic distal biceps tendon ruptures: Indications and use of tendon grafts

Reconstruction of chronic distal biceps tendon ruptures is complicated by the substantial retraction and poor quality of the remaining muscle and tendon tissue. Several types of tendon grafts have been described to augment the repair and restore length including both allografts and autografts. To date, we have found the Achilles tendon allografts to be perhaps the most reliable and versatile graft to reconstruct the chronic distal biceps tendon rupture and, when required, it has provided satisfactory clinical results in this difficult clinical setting.     

How to train war surgery specialists: Part II

Since 1950 the peacetime practice of civilian and military surgery has been characterized by increasing specialization and subspecialization. The surgical management of war wounds continues to require a solid foundation in general surgery training and experience, plus additional specific training in war surgery. Even the trauma specialist will face significant differences and difficulties treating war wounds in field hospitals. Neither military nor civilian surgical programs provide this training. This two-part essay identifies major characteristics of war surgery and explores the essential training and education required to prepare civilian and military surgeons for the practice of war surgery.     

Bone densitometry using computed tomography. Part II: increased trabecular bone density in children with chronic renal failure.

The method of gamma-ray computed tomography (gamma-ray CT) bone densitometry described in the preceding article provides selective determination of trabecular bone density (TBD), the relative amount of compact bone (bone density, BD), and the total absorption (TA) within a bone cross section. Seven of nine children with chronic renal failure (CRF), and selected only on the basis of their serum creatinine value (greater than 5 mg/100 ml), had increased TBD values above the normal range, whereas the other bone mineral parameters were normal. Radiographic signs of secondary hyperparathyroidism (subperiosteal erosions, cysts) were reported in the five patients with the highest TBD values, whereas the subjective diagnosis of osteosclerosis reported in three of these five and in one other patient correlated less well with the TBD increases. However, this is the first report of an objective, non-invasive documentation of the radiological finding of osteosclerosis in CRF. It also explains why methods for bone mineral measurements used previously, such as a photon absorptiometry which provides only a parameter equivalent to TA, failed to reveal increases in bone mineral content in renal osteodystrophy even when signs of osteosclerosis were present. Thus, gamma-ray CT helps to document objectively the degree of osteosclerosis and its location.     

Objective assessment of mammography systems. Part II: Implementation

A quality control program for mammography units was carried out, based on objective tests of image quality and dose. Results are reported for 31 units, including correlation between various parameters. Satisfactory results were obtained in the case of 21 installations; for the other 10, comparison between measured quality parameters and those of the reference system suggested ways in which quality might be improved.