A careful evaluation of scout CT lateral radiograph may prevent unreported vertebral fractures

Objectives

Our purpose was to review scout CT lateral radiographs to reveal osteoporotic vertebral fractures unreported by radiologists and to explore scout CT as a potential diagnostic tool in the detection of vertebral fractures.

Methods

We considered 500 patients (303 males, 197 females, age 64.6 ± 13.5 year-old). Our investigation was firstly focused on scout CT lateral images to detect vertebral fractures with a combined semiquantitative and quantitative diagnostic approach. Findings addressed to vertebral fracture were subsequently confirmed by multiplanar sagittal CT reconstructions. Whenever a vertebral fracture was discovered the radiologist report was read and a collection of patient anamnesis followed to understand whether fractures were already known.

Results

In 44/500 patients (8.8%) the evaluation on scout CT was incomplete or limited for patient/technical-based conditions, and 15 were excluded from the analysis. In 67/485 patients (13.8%) 99 vertebral fractures were detected. Among 67 fractured patients only 18 (26.9%) were previously diagnosed by radiologists. However, in the clinical history of 32 patients vertebral fractures were already known.

Conclusions

The perception and sensibility to vertebral fractures among radiologists are still poor when the assessment of the spine is not the aim of the examination. Short time spent for the evaluation of scout CT lateral radiographs could improve our accuracy.     

T2WI MRI and MRI-MDCT correlations of the osteoporotic vertebral compressive fractures

Purpose

The purpose of this study was to present the various vertebral bone signal and configuration patterns on T2WI MRI in osteoporotic benign fractures. The appearances were also assessed with thin slice MPR CT images.

Materials and methods

66 patients (43 women, 23 men; age range, 34–97 years; mean age, 76 years) with 100 vertebral compression fractures due to osteoporosis were included in our study. All cases are acute or subacute phase fractures which occurred within 1 month. Multiple fractures were observed in 29 patients, in 8 cases multiple concurrent fractures were proved by past radiograph or MRI. Three planes of T2WI (sagittal, coronal, axial) section images were correlated with the corresponding MDCT images.

Results

In our retrospective study, various signals and forms of vertebral body fractures were observed. The fracture zone (line) was classified 3 signal intensity patterns. (high; n = 24, low to intermediate; n = 16, low intensity; n = 38) on T2WI. The signal of the peri(para) fractured area were high (n = 6), intermediate to low (n = 41), low (n = 53)intensity. With CT correlative study, high, low to intermediate area were considered to be corresponded to the bone marrow edema, fibrous reparative tissue with/without the bony callus formation. The localization were as follows: sub-end plate band like lesion in 53, central in 16, anterior in 13, sub-endplate + anterior in 10, and complete (diffuse) in 8. In 10 cases, adjacent Schmorl's nodules were observed.

Conclusion

The various vertebral body signal patterns were observed in osteoporotic compressive fracture on T2WI. By MRI-CT correlations, high signal and low signal area on T2WI corresponded to the bone marrow edema, and the fibrous tissue or callus formation respectively.     

Prevalence of thoracolumbar vertebral fractures on multidetector CT: underreporting by radiologists

Objective

To evaluate the prevalence of osteoporotic vertebral fractures in patients undergoing multidetector computed tomography (MDCT) of the chest and/or abdomen.

Materials and methods

323 consecutive patients (196 males, 127 females) with a mean age of 62.6 years (range 20–88) who had undergone chest and/or abdominal MDCT were evaluated. Sagittal reformats of the spine obtained from thin section datasets were reviewed by two radiologists and assessed for vertebral fractures. Morphometric analysis using electronic calipers was performed on vertebral bodies which appeared abnormal upon visual inspection. A vertebral body height loss of 15% or more was considered a fracture and graded as mild (15–24%), moderate (25–49%) or severe (more than 50%). Official radiology reports were reviewed and whether the vertebral fractures had been reported or not was noted.

Results

31 out of 323 patients (9.5%) had at least 1 vertebral fracture and 7 of those patients had multiple fractures for a total of 41 fractures. Morphometric grading revealed 10 mild, 16 moderate and 15 severe fractures. Prevalence was higher in women (14.1%) than men (6.6%) and increased with patients age with a 17.1% prevalence in post-menopausal women. Only 6 out 41 vertebral fractures (14.6%) had been noted in the radiology final report while the remaining 35 (85.45) had not.

Conclusion

although vertebral fractures represent frequent incidental findings on multidetector CT studies and may be easily identified on sagittal reformats, they are often underreported by radiologists, most likely because of unawareness of their clinical importance.     

Sternal fracture in the emergency department: diagnostic value of multidetector CT with sagittal and coronal reconstruction images

Background

Multidetector CT (MDCT) is being increasingly used for patients with traumatic injuries in the emergency room. This is the first study to evaluate the diagnostic performance of MDCT for sternal fracture.

Patients and methods

For 87 patients who had motor vehicle accidents, we evaluated the diagnostic performance of MDCT for the sternal fractures. For 31 patients who underwent both MDCT and lateral radiography for the sternum, we compared the diagnostic performance of two examinations for the evaluation of sternal fracture.

Results

Thirty-two patients had sternal fractures and all the sternal fractures (sensitivity = 100%) were detected on MDCT, especially on the sagittal reconstruction images. However, the axial and coronal images detected 65% and 59% of all sternal fractures, respectively. For 31 patients who underwent both MDCT and lateral radiography for the sternum, MDCT showed superior diagnostic performance compared to that of radiography (accuracy = 97% and 77%, respectively, P = .02). For the one case that showed false positivity for sternal fracture on MDCT due to respiratory artifact, the lateral radiography enabled making the correct diagnosis.

Conclusion

Sternal fracture is frequently seen in patients who have blunt trauma injury secondary to motor vehicle accidents. MDCT, particularly sagittal images detect all of the sternal fractures, is superior to lateral radiography for diagnosis of sternal fracture. In the limited case that CT has severe motion artifact, additional radiography could help the diagnosis of sternal fracture.     

Isolated Tympanic Plate Fracture Frequency and Its Relationship to Mandibular Trauma

Purpose

This study evaluated the prevalence of isolated tympanic fractures and their correlation with mandibular fractures by using maxillofacial computed tomography (CT).

Materials and Methods

We retrospectively evaluated the maxillofacial CT of 1590 patients who presented to our emergency department with maxillofacial trauma between December 2010 and December 2012. Maxillofacial CT was used as the criterion standard for evaluating patients with maxillofacial fractures. The CT images were evaluated by using an electronic picture archiving and communications system and interpreted independently by 2 radiologists.

Results

The maxillofacial CT images revealed mandibular fractures in 167 of the patients and isolated tympanic plate fractures in 35 of these 167 patients. Four patients (11%) had a bilateral tympanic plate fracture, and 31 patients (89%) had unilateral tympanic plate fracture. Of all the tympanic plate fractures, 19 (54%) were on the right side and 16 (46%) were on the left side (P > .05). In our results, a significant correlation between the presence of a right-sided tympanic plate fracture and fracture of the ipsilateral condylar process was found (P = .036). However, a statistically significant difference between the presence of a tympanic plate fracture and other mandible fractures, additional soft-tissue findings, or the number of fractures was not determined (P > .05). Sex had no impact on the presence of tympanic plate fracture (P > .05).

Conclusion

The frequency of isolated tympanic plate fractures in maxillofacial trauma is low, but it is an important anatomic location. Condyle fractures are significantly associated with isolated tympanic plate fractures. The presence of these injuries should raise suspicion of a concomitant isolated tympanic plate fracture.     

Spinous process fractures in osteoporotic thoracolumbar vertebral fractures

Objectives

To evaluate the incidence and pattern of spinous process fractures (SPFs) in patients with osteoporotic compression fractures (OCFs) of the thoracolumbar spine.

Methods

Spinal MRI or CT of 398 female patients (age range 50–89 years, mean age 70 years) who had OCFs in the thoracolumbar spine were retrospectively reviewed. The incidence, location and imaging results for the SPFs were evaluated.

Results

Of the 398 patients who had thoracolumbar OCFs, 14 (3.5%) had SPF. In six patients with single compression fractures, the SPF occurred at the level just above the vertebral compression fracture. In six out of seven patients with multiple continuous compression fractures, the SPF occurred just one level above the uppermost level of the compression fracture. The remaining one patient who had thoracolumbar spinal fixation at T12–L2 with continuous compression fractures in T12–L5 had a SPF in L2. In one patient who had multiple compression fractures in discontinuous levels (fractures at T10 and L1, respectively), the SPF occurred at T12. The directions of the fractures were vertical or oblique vertical (perpendicular to the long axis of the spinous process) in all cases.

Conclusion

In the presence of an OCF in the thoracolumbar spine, a SPF was found in 3.5% of cases, and most of the fractures were located just one level above the compression fracture. Therefore, in patients who have OCF, the possibility of a SPF in the level just above the compression fracture should be considered.Osteoporosis is a common disease owing to an increase in the population of older people. Osteoporosis is a disease that induces bone fragility, caused by a decrease in trabecular bone, and the resulting fracture is called an insufficiency fracture. The most common osteoporotic compression fractures occur in the spine, sacrum, pubis, femoral neck and wrist [1].Although the most common methods for imaging vertebral fractures are still spinal radiographs, benign spinal compression fractures are commonly detected by MRI or CT on osteoporotic patients with back pain. Sometimes, it is difficult to differentiate a benign spinal compression fracture from a malignant cause of the spinal compression fracture. However, in most cases, a benign spinal compression fracture shows some specific features: a low-signal-intensity band on T₁ and T₂ weighted images, spared normal bone marrow signal intensity of the vertebral body, retropulsion of a posterior bone fragment and multiple compression fractures [2]. A relationship between osteoporosis and benign spinal compression fractures, including insufficiency fractures, has been reported. A study examining the relationship between benign compression fractures of the spine and insufficiency fractures of the sacrum has also been reported [3]. However, there have been few reports of spinous process fractures in the osteoporotic spine [4]. Moreover, there have been no studies examining the relationship between spinous process fractures and benign compression fractures of the spine.We have noted index cases of spinous process fractures in certain patients with osteoporotic compression fractures. There has been no report of spinous process fractures in patients with osteoporotic compression fractures. The aim of this study was, therefore, to evaluate the relationship between osteoporotic compression fractures and spinous process fractures in patients with osteoporosis.     

Role of postoperative multislice computed tomography in assessment of pedicle screw placement in spinal surgical fixation

Objective

To evaluate the role of three-dimensional (3D) volume rendering computed tomography (CT), in the postoperative assessment of pedicle screw placement.

Methods

Ninety-eight patients with previous spinal fixation surgery were included. All inserted screws were evaluated post operatively within the first month using CT. Degree of misplacement and difference between CT images were recorded.

Results

Seventy six, 68 and 39 misplaced screws were detected in 3D reformatted image, coronal reconstruction and axial CT images, respectively. Dorsal spine had the higher rate of violation of 46 (9.95%) with the highest rate at T4 (12.8%) compared with lumbar of 32 (6.9%). Statistically significant differences were found between lateral and medial violation (P value −0.03), between findings of 3D CT reformatted and axial images (P = 0.04), and also in detecting end plate perforation and anterior vertebral encroachment in different CT images (P value −0.013). Sensitivity for 3D reformatted image and axial image compared with surgical finding in six revised screws was 100% and 95.8% and specificity was 100% and 88.7%, respectively. Highly momentous agreement is reported with Kappa coefficient = 0.95 ± <0.001.

Conclusion

We conclude that postoperative evaluation of pedicle screw using 3D CT reconstruction was a reliable method.     

A vast increase in the use of CT scans for investigating occult hip fractures

Background

Early diagnosis in neck of femur fractures has been shown to improve outcome. The National Institute for Clinical Excellence recommends if an occult hip fracture is suspected then an MRI should be performed and if not available within 24 h a CT should be considered. At our centre, emergency MRI is rarely available and so CT is commonly used.

Objectives

Our study aims to analyse the trends in CT use over a five year period for the diagnosis of neck of femur fractures.

Methods

Both the number of patients with a hip fracture and those undergoing a CT hip to diagnose an occult injury were identified across two district general hospitals between 2006–2007 and 2010–2011. The time from initial radiograph to CT and initial radiograph to operation were calculated.

Results

In 2006–2007, of 547 hip fractures, 20 CT hips were performed and 6 reported as a fractured neck of femur (30%). In 2010–2011, of 499 hip fractures, 239 CT hips were performed and 65 fractures were recognised (27%). The mean time from radiograph until CT scan was 2.0 days in 2007 and 3.2 days in 2011, which was a statistically significant difference (p < 0.001). For those diagnosed using a CT scan the mean time from admission X-ray to surgery was 1.2 days in 2007 and 3.6 days in 2011.

Conclusion

Clinicians are becoming increasingly reliant on CT for the diagnosis of hip fractures with our data suggesting further imaging is one factor that can delay time to diagnosis and theatre.     

Angiographic frequency of blunt cerebrovascular injury in patients with carotid canal or vertebral foramen fractures on multidetector CT

Purpose

Blunt carotid injuries (BCI's) and blunt vertebral artery injuries (BVI's), known jointly as BCVI's, are common in “high risk” patients. The purpose is to evaluate the rate of occurrence of BCI/BVI in patients screened purely by the radiologic criteria of fracture through the carotid canal or vertebral transverse foramina, or significant cervical subluxation, noted by multidetector CT.

Methods

Seventy-one patients with 108 catheterized vessels were included over a 13-month interval. The angiographic examinations were prompted by current hospital protocol, solely by the presence of fractures involving/adjacent to the carotid canal, cervical fractures involving/adjacent to the foramen transversarium, or cervical fractures with significant subluxation. The incidence of each grade of blunt injury was calculated after review of the CT scans and catheter angiograms by two neuroradiologists.

Results

Two thousand and seventy-three total blunt trauma admissions occurred during the time period, with a BCVI rate of 0.92–1.0% (depending on the reviewer), similar to previous studies. Mean time to catheter angiography was 16.6 h. Of the 71 included patients, there were 11–12 BCI's and 10–12 BVI's, an overall rate of 27–30% of BCVI in the patients with foraminal fractures. Interobserver agreement in reviewing the catheter angiograms was excellent (Kappa 0.795). Of note, three internal carotid pseudoaneurysms resolved spontaneously after anticoagulation or aspirin.

Conclusion

This study confirms that there is a high rate of BCVI in the presence of carotid canal or vertebral foramen fractures that are noted by multidetector CT. Utilization of purely radiologic criteria of foraminal involvement may be a significant screening tool in the decision of whether to evaluate these patients acutely by catheter or CT angiography, and for early detection of patients at risk for symptomatology, to initiate prompt, prophylactic treatment.     

Diagnostic value of apparent diffusion coefficient to differentiate benign from malignant vertebral bone marrow lesions

Background

Vertebral collapse is a common problem due to benign bone marrow lesions, trauma or malignant process. The diagnosis is often correctly predicted from characteristic imaging appearance. Some vertebral collapses have atypical imaging appearance that may cause diagnostic confusion.

Aim

To evaluate the value of the ADC obtained in DW-MR sequences for the differentiation between benign and malignant bone marrow lesions.

Patients

Sixty patients were included in this study, referred from Neurosurgery and Radiotherapy Departments and proved to have vertebral compression based on conventional MR imaging.

Results

The ADC value resulted in statistically significant characterization between (osteoporotic and post-traumatic collapse) and (malignant vertebral collapse) (P < 0.0001) while there was no statistically significant findings between infective spondylodiscitis and malignant vertebral collapse (P > 0.05). The sensitivity, specificity, PPV, NPD of DWI and ADC values in differentiating benign from malignant vertebral collapse were 100%, 83.3%, 60% and 100% respectively.

Conclusions

ADC values are a useful complementary MRI tool to characterize bone marrow lesions, in order to distinguish acute benign fractures from malignant or infectious bone marrow lesions. However, ADC values are not valuable in order to differentiate malignancy from infection with diagnostic overlap in the subacute traumatic vertebral collapse.     

The role of multi detector computerized tomography in evaluation of maxillofacial fractures

Objective

The purpose of our study was to assess the role of multi-detector CT in the evaluation of maxillofacial fractures.

Subjects and methods

The study included 30 patients complaining from facial trauma with suspected facial fractures referred from the emergency unit of the El-Minia University Hospital. All patients subjected to non contrast MDCT in axial cuts and images are transferred to workstation then they underwent coronal, sagittal reconstructed images and 3-D volume rendering that are of benefit in final diagnosis.

Results

A total of 30 patients were included (their mean age 26 years). It was found that the nasal bone is most common to be fractured (found in 19 cases), followed by maxillary bone (17 cases), zygomatic bone (10 cases), mandibular bone (8 cases) and the pterygoid plates are least frequent to be fractured (6 cases). Also, concerning the complex facial fractures; the orbital wall fractures are the most frequent (found in 22 cases), followed by zygomatico-maxillary complex fractures (8 cases), the naso-orbito-ethmoid fractures (6 cases), and lastly comes the Le Forte fractures (found in 4 cases).

Conclusion

The use of MDCT is mandatory for the accurate classification of maxillo-facial fractures and so the management decision.     

Assessment of osteoporotic vertebral fractures using specialized workflow software for 6-point morphometry

Purpose

To evaluate the time required, the accuracy and the precision of a model-based image analysis software tool for the diagnosis of osteoporotic fractures using a 6-point morphometry protocol.

Materials and methods

Lateral dorsal and lumbar radiographs were performed on 92 elderly women (mean age 69.2 ± 5.7 years). Institutional review board approval and patient informed consent were obtained for all subjects. The semi-automated and the manual correct annotations of 6-point placement were compared to calculate the time consumed and the accuracy of the software. Twenty test images were randomly selected and the data obtained by multiple perturbed initialisation points on the same image were compared to assess the precision of the system.

Results

The time requirement data of the semi-automated system (420 ± 67 s) were statistically different (p < 0.05) from that of manual placement (900 ± 77 s). In the accuracy test, the mean reproducibility error for semi-automatic 6-point placement was 2.50 ± 0.72% [95% CI] for the anterior–posterior reference and 2.16 ± 0.5% [95% CI] for the superior–inferior reference. In the precision test the mean error resulted averaged over all vertebrae was 2.6 ± 1.3% in terms of vertebral width.

Conclusions

The technique is time effective, accurate and precise and can, therefore, be recommended in large epidemiological studies and pharmaceutical trials for reporting of osteoporotic vertebral fractures.     

Automatic detection of osteoporotic vertebral fractures in routine thoracic and abdominal MDCT

Objectives

To develop a prototype algorithm for automatic spine segmentation in MDCT images and use it to automatically detect osteoporotic vertebral fractures.

Methods

Cross-sectional routine thoracic and abdominal MDCT images of 71 patients including 8 males and 9 females with 25 osteoporotic vertebral fractures and longitudinal MDCT images of 9 patients with 18 incidental fractures in the follow-up MDCT were retrospectively selected. The spine segmentation algorithm localised and identified the vertebrae T5-L5. Each vertebra was automatically segmented by using corresponding vertebra surface shape models that were adapted to the original images. Anterior, middle, and posterior height of each vertebra was automatically determined; the anterior-posterior ratio (APR) and middle-posterior ratio (MPR) were computed. As the gold standard, radiologists graded vertebral fractures from T5 to L5 according to the Genant classification in consensus.

Results

Using ROC analysis to differentiate vertebrae without versus with prevalent fracture, AUC values of 0.84 and 0.83 were obtained for APR and MPR, respectively (p?<?0.001). Longitudinal changes in APR and MPR were significantly different between vertebrae without versus with incidental fracture (ΔAPR: -8.5 %?±?8.6 % versus -1.6 %?±?4.2 %, p?=?0.002; ΔMPR: -11.4 %?±?7.7 % versus -1.2 %?±?1.6 %, p?<?0.001).

Conclusions

This prototype algorithm may support radiologists in reporting currently underdiagnosed osteoporotic vertebral fractures so that appropriate therapy can be initiated.

Key points

? This spine segmentation algorithm automatically localised, identified, and segmented the vertebrae in MDCT images. ? Osteoporotic vertebral fractures could be automatically detected using this prototype algorithm. ? The prototype algorithm helps radiologists to report underdiagnosed osteoporotic vertebral fractures.     

Comparison of diagnostic accuracy of Magnetic Resonance Imaging and Multidetector Computed Tomography in the detection of pelvic fractures

Objective

To compare diagnostic accuracy and interobserver reliability of Magnetic Resonance Imaging (MRI) and Multidetector Computed Tomography (MDCT) in the detection of acute pelvic fractures.

Materials and methods

In 38 consecutive patients (mean age 74.7 years) with a positive finding of anterior pelvis fracture in the conventional X-rays, pelvic MRI and MDCT were performed for further evaluation of pelvic ring fractures. Two radiologists independently read all data sets. Sensitivity and specificity were calculated based on mean scores for each method. Sensitivities of CT and MRI were compared using a paired proportion test (McNemar). Diagnostic validity of both methods was assessed by the interobserver variability using kappa statistics. Combined clinical data and findings from all imaging studies served as the reference standard.

Results

122 fractures were identified in the reference standard (37 sacral, 58 pubic, 22 acetabular, 1 ischial, 4 ilial). On average, MRI detected 96.3% whereas CT detected 77% of all fractures. With regard to sensitivity, MRI proved to be significantly better compared to MDCT (observer 1, p = 0.0009; observer 2, p = 0.0003 by observer 2). In particular, MRI performed better in the depiction of sacral fractures, reaching a sensitivity of 98.6% compared to 66.1% at CT. The interobserver variability was determined to be very good (k = 0.955 for MRI and 0.902 for MDCT).

Conclusion

MRI reaches a significantly higher sensitivity than CT in the detection of acute pelvic fractures, particularly of the sacrum. Especially in elderly patients with suspicion of a sacral fracture and negative results at MDCT, MRI may be considered as the next step in diagnostic workup.     

Treatment response assessment of radiofrequency ablation for hepatocellular carcinoma: usefulness of virtual CT sonography with magnetic navigation

Purpose

Virtual CT sonography using magnetic navigation provides cross sectional images of CT volume data corresponding to the angle of the transducer in the magnetic field in real-time. The purpose of this study was to clarify the value of this virtual CT sonography for treatment response of radiofrequency ablation for hepatocellular carcinoma.

Patients and methods

Sixty-one patients with 88 HCCs measuring 0.5–1.3 cm (mean ± SD, 1.0 ± 0.3 cm) were treated by radiofrequency ablation. For early treatment response, dynamic CT was performed 1–5 days (median, 2 days). We compared early treatment response between axial CT images and multi-angle CT images using virtual CT sonography.

Results

Residual tumor stains on axial CT images and multi-angle CT images were detected in 11.4% (10/88) and 13.6% (12/88) after the first session of RFA, respectively (P = 0.65). Two patients were diagnosed as showing hyperemia enhancement after the initial radiofrequency ablation on axial CT images and showed local tumor progression shortly because of unnoticed residual tumors. Only virtual CT sonography with magnetic navigation retrospectively showed the residual tumor as circular enhancement. In safety margin analysis, 10 patients were excluded because of residual tumors. The safety margin more than 5 mm by virtual CT sonographic images and transverse CT images were determined in 71.8% (56/78) and 82.1% (64/78), respectively (P = 0.13). The safety margin should be overestimated on axial CT images in 8 nodules.

Conclusion

Virtual CT sonography with magnetic navigation was useful in evaluating the treatment response of radiofrequency ablation therapy for hepatocellular carcinoma.     

Imaging differentiation of pathologic fractures caused by primary and secondary bone tumors

Objective

To describe pre-treatment imaging features of pathologic fractures caused by primary bone tumors (PBTs) and metastatic bone tumors (MBTs) and determine if radiographic or cross-sectional features can differentiate the underlying pathologies associated with the fractures.

Methods

Sixty-nine patients with a diagnosis of a pathologic fracture were enrolled. Biopsy established PBT as the cause of the pathologic fracture in 16 (23%) cases and MBT in 53 (77%) cases. The radiographs, computed tomography (CT) scans, and magnetic resonance imaging (MRI) scans of the subjects were retrospectively reviewed for the presence of multiple imaging features.

Results

Compared to pathologic fractures caused by MBTs, the fractures caused by PBTs demonstrated a higher incidence of lytic bone cortex, mineralization and a soft-tissue mass on radiographs, mineralization and a soft-tissue mass on CT scans, and periosteal abnormality on MRI scans (P < 0.01). These features also exhibited a high negative predictive value in supporting the diagnosis of an underlying PBT over MBT.

Conclusion

Pathologic fractures caused by PBT and MBT may be differentiated by a few specific radiographic and CT imaging features, though MRI was poor for characterization of the underlying lesion. Such knowledge may assist radiologists in raising the possibility of a PBT as the cause of a pathologic fracture.     

The "communication line" suggests occult posterior malleolar fracture associated with a spiral tibial shaft fracture

Objectives

To demonstrate radiographical characteristics of the relationship between distal spiral tibial shaft fractures and associated occult posterior malleolar fractures (PMF) that confirmed by CT and MRI.

Materials and methods

X-rays for a ninety-six patients with spiral tibia fracture and associated PMF were reviewed. All patients additionally had an ankle CT. Patients with a negative CT scans underwent an ankle MRI. Radiographic observations included fracture location, characteristics, and a presence of a fracture line between the two injuries.

Results

The spiral tibia fracture line was contiguous with PMF in 89 of 96 cases after evaluation with the CT and MRI. The line connecting the two injuries, which occurs between the medial inferior apex of the spiral tibia fracture line and the posterior superior apex of the PMF was identified as the “communication line”. In 47 of the 89 conjunction fractures, the “communication line” was detectable preoperatively and in 12 cases postoperatively by anteroposterior radiograph. By using the CT and MRI scans, we found that no “communication line” was present in only 7 cases.

Conclusion

It is important to understand the nature of the association between distal spiral tibial shaft fractures and occult posterior malleolar fractures for optimal stabilization of the fracture and for appropriate rehabilitation. The “communication line” is a useful diagnostic clue for early recognition the occult PMF and alerts a closer evaluation of the lateral view and further CT examination.     

Differentiation of acute osteoporotic from malignant vertebral compression fractures with conventional MRI and diffusion MR imaging

Aim

To evaluate the role of using a single shot spin echoplanar DW sequence (SSSEP-DWI) compared to conventional MRI and contrast enhanced T1WI in differentiation between vertebral osteoporotic fractures and malignant compression fractures. The sensitivity and specificity of (SSSEP-DWI) will also be calculated.

Computational area measurement of orbital floor fractures: reliability, accuracy and rapidity

Objective

To evaluate the reliability, accuracy and rapidity of a specific computational method for assessing the orbital floor fracture area on a CT scan.

Method

A computer assessment of the area of the fracture, as well as that of the total orbital floor, was determined on CT scans taken from ten patients. The ratio of the fracture's area to the orbital floor area was also calculated. The test–retest precision of measurement calculations was estimated using the Intraclass Correlation Coefficient (ICC) and Dahlberg's formula to assess the agreement across observers and across measures. The time needed for the complete assessment was also evaluated.

Results

The Intraclass Correlation Coefficient across observers was 0.92 [0.85;0.96], and the precision of the measures across observers was 4.9%, according to Dahlberg's formula .The mean time needed to make one measurement was 2 min and 39 s (range, 1 min and 32 s to 4 min and 37 s).

Conclusion

This study demonstrated that (1) the area of the orbital floor fracture can be rapidly and reliably assessed by using a specific computer system directly on CT scan images; (2) this method has the potential of being routinely used to standardize the post-traumatic evaluation of orbital fractures.     

Combined Vertebral Fracture Assessment and Bone Mineral Density Measurement: A Patient-friendly New Tool with an Important Impact on the Canadian Risk Fracture Classification

Purpose

Vertebral fractures often go unnoticed, while they constitute a significant risk factor for new fractures, independent of the bone density. Vertebral Fracture Assessment (VFA) is a new feature on DXA bone densitometry equipment. Our purpose was to determine the added value of VFA and its impact on the Canadian fracture risk classification using data from a Dutch academic cohort.

Methods

All 958 consecutive patients (64% female, mean age 53 [20–94], mean weight 75 kg [32–150]) who underwent BMD measurement at the University Medical Center Groningen, The Netherlands also underwent VFA in the same session.

Results

The prevalence of vertebral fractures was 26%. In 68% of these patients this fracture was unknown. The severity was “mild” (20%–25% height loss) in 43%, “moderate” (25%–35%) in 44% and “severe” (>35% height loss) in 13%. Even after excluding mild fractures, the prevalence of vertebral fractures was 17%. In the 28% with normal BMD the vertebral fracture prevalence was still 18%, in the 43% with osteopenia 23%, and in the 29% with osteoporosis 36%. The Canadian risk classification was “low fracture risk” in 68%, “moderate” in 19%, and “high” in 13%. Adding VFA altered the classification in 20% of the patients, to become 54%, 27%, and 19%, respectively.

Conclusions

VFA added to BMD is a patient friendly diagnostic tool with a high diagnostic yield, as it detected unknown vertebral fractures and altered diagnostic classification in approximately 1 out of every 5 patients. These results suggest that BMD plus VFA may become the new standard in osteoporosis testing.