Avulsion of the common hamstring tendon origin in an active duty airman

Hamstring injuries are common in active athletic populations, such as military service members. Ruptures of the hamstring origin from the ischial tuberosity are rare injuries and missed if not considered in the differential diagnosis of ischial pain. Unlike other hamstring injuries, complete hamstring avulsions must be treated surgically. Results of untreated hamstring avulsions are poor. The purpose of this article is to describe the case of an active duty airman who presented for an unrelated complaint and was discovered to have a 5-week-old hamstring avulsion. Surgical repair of the hamstring avulsion 6 weeks after injury yielded an excellent result and return to full duty. Hamstring avulsions recognized early by history and physical examination and diagnostic imaging permits early and effective treatment. Early surgical repair of the tendon to bone can result in return to full duty.     

Wrist Trauma: More Than Bones

Acute and subacute wrist trauma predominantly consist of fractures of the distal radius in elderly patients and most frequently carpal fractures (scaphoid, followed by triquetrum and hamatum) and avulsion fractures of the ulnar styloid in younger patients, especially in sports-related injuries but also in work activities. The initial radiographs may miss the fractures and result when untreated in complications as nonunion, osteonecrosis, and degenerative osteoarthritis.Fractures of the distal radius and of the scaphoid may be associated with ligament injuries, most frequently the scapholunate complex, which are often overlooked at the emergency department. Patients without osseous injuries may present intrinsic and extrinsic ligament tears that may lead to carpal instability when they are clinically and/or radiologically missed.Therefore, in acute and subacute setting, computed tomography may be helpful for the detection of subtle fractures, and magnetic resonance imaging, for the early diagnosis of occult fractures and ligament injuries.     

Imaging of the hamstrings

The hamstring muscles, located in the posterior thigh, include the biceps femoris, the semimembranosus, and the semitendinosus. The proximal portions of the hamstring muscles are subject to a variety of injuries and pathology. Many of these entities affect the origin of the hamstrings, including the tendinous enthesis, the underlying ischial tuberosity, and the surrounding tissues. Tendinosis and small partial tears at the origin are the result of chronic attrition. They may be accompanied by bursitis or hamstring syndrome. Apophysitis occurs in teenagers prior to complete fusion of the ischial apophysis and results from repeated traction injuries on the apophysis without discrete displacement. Abrupt injury at the origin from forced flexion of the hip results in osseous avulsions of the apophysis in teenagers and proximal tendon ruptures in adults. Other entities affect the muscles distal to the tendon origins. These injuries include strains and partial tears of the musculotendinous junction from acute indirect trauma, delayed onset muscle soreness from overuse of the muscle group without discrete remembered injury, and contusions and myositis ossificans from direct blunt impact. The imaging features of these injuries and pathology are fairly specific and diagnostic, with the exception of some cases of myositis ossificans and chronic ischial avulsions.     

Imaging features of avulsion injuries.

Avulsion injuries are common among participants in organized sports, especially among adolescent participants. Imaging features of both acute and chronic avulsion injuries of the pelvis, knee, ankle and foot, shoulder, and elbow were evaluated to help distinguish these injuries from more serious disease processes such as neoplasm and infection. At radiography, acute injuries (ie, those resulting from extreme, unbalanced, often eccentric muscular contractions) may be associated with avulsed bone fragments, whereas subacute injuries have an aggressive appearance that may include areas of mixed lysis and sclerosis. Chronic injuries (ie, those resulting from repetitive microtrauma or overuse) or old inactive injuries may be associated with a protuberant mass of bone and may bear a striking resemblance to a neoplastic or infectious process. Although not usually required, computed tomography is helpful in the diagnosis if radiographic findings are equivocal or if the injury is not in the acute phase. MR imaging is best suited for the evaluation of injuries to muscles, tendons, and ligaments. Recognition of characteristic imaging features and familiarity with musculotendinous anatomy will aid in accurate diagnosis of avulsion injuries.     

Diving-type injury of the cervical spine: contribution of computed tomography to management.

We have utilized computed tomography (CT) in addition to conventional radiography for evaluation and as a guide to management of serious diving injuries to the cervical spine. This technique has proven to be invaluable in the initial assessment and further clinical management of this type of injury. A classification of these injuries and associated fractures is presented based on CT appearance. Representative cases are presented comparing standard radiography and CT.     

Injuries to the superior ankle joint from the viewpoint of accident surgery]

The treatment of bony, osteochondral, and ligamentous injuries of the tibio-talar joint requires precise preoperative planning by radiological investigation. This is essential to a correct understanding of the underlying pathology and will allow a proper classification of the injury, which is the basis of treatment. Conventional radiography using anteroposterior and lateral X-rays with comparative views of the noninjured side and, if necessary, rotated spot views and tomography are of high value especially in osteochondral fractures of the talus. Intraoperative control images in both planes after osteosynthesis are mandatory. For evaluation of the postoperative course and severity of arthrosis formation, the classification system of Bargon has proved its worth. In addition, tomography of the tibio-talar joint in two planes is useful especially in tibial pilon fractures, some malleolar fractures, and peripheral talar fractures. In talar fracture dislocations with concomitant compartment syndrome an emergency CT scan can be helpful to determine the optimal surgical approach. In these cases a 3-D reconstruction also might be of assistance. If there is evidence of partial or total talar necrosis, magnetic resonance imaging can be extremely helpful. However, in most cases implants considerably limit the validity of the image obtained. Ultrasonography offers a noninvasive, reproducible, and very inexpensive alternative and should be performed in cases of chondral-osteochondral talar rim avulsions and juvenile osteochondral ligament ruptures. It can also be used as a dynamic method for stress examination in fibular ligament ruptures and soft tissue injuries such as dislocation of the peroneal tendons. The use of Arthrography, stress tenography, and Arthro-CT scan nowadays has become extremely limited.     

Comparison of CT and MRI in patients with tibial plateau fracture: can CT findings predict ligament tear or meniscal injury?

Objective (1) To determine the accuracy of computed tomography (CT) in the evaluation of ligament tear and avulsion in patients with tibial plateau fracture. (2) To evaluate whether the presence or severity of fracture gap and articular depression can predict meniscal injury. Design and patients A fellowship-trained musculoskeletal radiologist retrospectively reviewed knee CT and MRI examinations of 41 consecutive patients presenting to a level 1 trauma center with tibial plateau fractures. Fracture gap, articular depression, ligament tear and footprint avulsions were assessed on CT examinations. The MRI studies were examined for osseous and soft tissue injuries, including meniscal tear, meniscal displacement, ligament tear, and ligament avulsion. Results CT demonstrated torn ligaments with 80% sensitivity and 98% specificity. Only 2% of ligaments deemed intact on careful CT evaluation had partial or complete tears on MRI. Although the degree of fracture gap and articular depression was significantly greater in patients with meniscal injury compared with those without meniscal injury, ROC analysis demonstrated no clear threshold for gap or depression that yielded a combination of high sensitivity and specificity. Conclusions In the acute setting, CT offers high sensitivity and specificity for depicting osseous avulsions, as well as high negative predictive value for excluding ligament injury. However, MRI remains necessary for the preoperative detection of meniscal injury.     

Acute tibial tubercleavulsion fractures

Acute tibial tubercle avulsion fractures are commonly seen in athletes involved with jumping sports, especially basketball. These injuries typically occur in well-muscled, mature-appearing boys, 15 to 16 years of age, who generate high tensile forces at the tubercle junction. Possible associated injuries include patellar and quadriceps tendon avulsions, as well as collateral and cruciate ligament and meniscal damage. Treatment is based on the magnitude of injury. Recovery is rapid and the outcome is usually excellent, even in type III injuries.     

Traumatic injuries: imaging of peripheral musculoskeletal injuries

The current dominant role of conventional radiography must be reassessed at increasingly shorter intervals in view of the continuing emergence of new imaging modalities that are available to diagnose peripheral musculoskeletal injuries. In comparison with conventional radiography, digital radiographic techniques offer advantages for optimization of image quality and dose, such as a wider dynamic range and post-processing of images. Currently, digital luminescence radiography (storage phosphor radiography) is the most commonly used digital method for obtaining radiographs, using the established positioning projections and routines of the film-screen technique. A new process, radiography with flat-panel amorphous silicon detectors, is still under development. Computed tomography is a valuable tool for diagnosing injuries of the peripheral musculoskeletal system, especially when three-dimensional data sets are acquired; these allow reformating images in all planes desired (2D technique) or in a volumetric format (3D technique). Established indications for CT in the peripheral skeleton are hip fractures, wrist injuries and calcaneal fractures; however, CT may be used as a supplement to radiography in every region of the body. Sonography is beginning to play an increasingly important role in trauma. Muscle and tendon injuries are the most common indications, but worthwhile information can be gained of the shoulder, elbow, hip, and knee joints, supplementing conventional or digital radiography. Magnetic resonance imaging effectively visualizes traumatic changes of the skeleton and the peripheral soft tissues. It is the method of choice to detect occult fractures. It can be used to diagnose muscle and tendon injuries. Joint injuries, especially in the knee and the shoulder joint, are common indications for MRI in the posttraumatic setting.     

High clinical utility of computed tomography compared to radiography in elderly patients with occult hip fracture after low-energy trauma

To evaluate the clinical utility of computed tomography (CT) compared to radiography in evaluating suspect or missed hip fractures in elderly after low-energy trauma. One hundred ninety-three hip CT examinations performed in two trauma centers during 3 years of evaluation of clinically suspect or occult hip fracture within 24 h of negative or suspect radiography were retrospectively reviewed. Consensus CT diagnosis by three observers was compared to clinical outcome and in some cases also further imaging. All patients were elderly and had sustained a low-energy trauma. Eighty-four examinations revealed no fracture. Follow-up was uneventful but for two patients who had been operated. Thirty-nine of 41 cervical hip fractures were surgically or otherwise confirmed, two cases were not operated due to week-old trauma and moderate symptoms. Twenty-nine of 68 trochanteric fractures or avulsions were confirmed surgically. Computed tomography has a high clinical utility as it can detect nearly all clinically suspect but radiographically negative cervical hip fractures as well as most trochanteric fractures and avulsions. A negative CT is near-perfect in ruling out a hip fracture requiring surgery.     

Occipitocervical fracture-subluxation

Except for frank occipitoatlantal dislocation, injuries of the occipitovertebral junction usually are invisible on the lateral cervical spine radiograph and are heralded by changes in the cervicocranial prevertebral soft tissues. The latter require computed tomography for further evaluation. With a minimal degree of subluxation of the occipital condyles relative to C1, the appearance on the lateral radiograph may be deceptively normal. The occipital condyles are poorly seen on the lateral plain films of the cervical spine owing to overlying structures, and occipital condylar fractures may not be visible.     

Avulsion fractures of the pelvis in children: a report of 32 fractures and their outcome

Avulsion injuries of the apophyses of the pelvis are mainly athletic injuries and are usually seen in adolescents. In a series of 80 pelvic fractures in children seen and managed in The Royal Liverpool Children's Hospital, Alder Hey, in the last 10 years, 32 avulsion fractures in 25 patients were diagnosed and treated. Twenty-two of these patients were followed for an average of 44 months (range 4–120 months). Eight (33%) were girls, a higher proportion than in other published series. The average age of the children was 13.8 years. These fractures, though generally regarded as trivial injuries, have left disability persisting into adult life, with limitation of sporting ability in 10 of the 22 patients and persistent symptoms in 6, mostly in those with ischial avulsion injuries. Fourteen patients with acute injuries needed hospitalisation, with an average stay of 5 days. The other 11 were suffering from chronic traction injuries sustained in sport. This distinction between acute and chronic injuries has not been emphasized in the other reviews. The radiological appearances, diagnostic problems and morbidity are discussed in order to increase awareness of these injuries.     

Imaging findings of acute intravascular thrombus on non-enhanced computed tomography

Intravascular thrombosis and thromboembolism are critical diagnoses which are frequently made on contrast-enhanced computed tomography (CECT) or Doppler ultrasound. For a variety of reasons, some patients with acute intravascular pathology are imaged using CT without intravenous contrast. In the acute setting, the increased Hounsfield unit (HU) density of the thrombus compared to the blood pool allows the diagnosis to be made, or at least suggested, on non-enhanced computed tomography (NECT). The increased density of the clot is commonly referred to as the “hyperdense vessel sign.” This is a well-known finding in the setting of stroke, but hyperdense vessels can also signal arterial or venous thrombosis in the chest, abdomen, pelvis, and extremities. Once a hyperdense vessel sign is noted on NECT, further exploration with CECT, angiography, or ultrasound may then be performed. Here, we present a pictorial review of the appearance of acute intravascular thrombosis as seen on non-enhanced computed tomography.     

The treatment of avulsion fractures of the tibial tuberosity in adolescent athletes

Avulsion fractures of the tibial tuberosity occur mainly during sport activities and are closely related to the strains exerted on the anterior tibial tuberosity by the extension complex of the thigh. A knowledge of the mechanical aspects of these avulsions may improve understanding of the mechanisms of such injuries. In such avulsion fractures, tensile forces due to the contraction of the quadriceps complex overcome the cohesive forces within the apophyseal cartilage. A 1-month cast immobilisation on an extended knee gives good results in the management of nondisplaced fractures. In minor displacements, such immobilisations follow closed external reductions. Open reductions and stable screw fixations precede a 3-week immobilisation for displaced fractures. Long term results are regularly good in well-managed cases.     

Stressfrakturen

Bone stress injuries are due to repetitive mechanical overuse of the skeleton and occur as a result of microscopic lesions sustained when bone is subjected to repeated submaximal stress. Over time accumulation of such injuries can lead to bone failure and fractures. Stress-related bone injuries are relatively common among otherwise healthy persons who have recently started new or intensified forms of physical training activities. Stress injuries lead to typical findings on radiography, bone scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI) and need to be discriminated from other conditions, in particular infections and neoplasms. Stress fractures must be differentiated from insufficiency fractures that occur in bones with reduced mechanical resistance or disturbed structure.     

Evaluation of the hamstring muscle complex following acute injury

Objective To evaluate the imaging findings following acute hamstring injury.Design and patients We retrospectively reviewed the imaging findings of hamstring muscle complex (HMC) strain in 170 patients referred to our institution over a 3-year period. A total of 179 injuries to the HMC were demonstrated in 170 patients (154 male, 16 female, mean age 28.2 years). The mean duration of symptoms was 4.7 days (range 1–10 days). MR imaging was performed in 97 cases and sonography in 102 cases (both modalities were performed in 20 examinations). Attention was directed to the frequency of muscle involvement, the location of the injury within the muscle-tendon unit, the extent of the injury and discriminating avulsion from muscle injury.Results and conclusions Twenty-one patients had proximal tendon injury, with sixteen avulsions and five partial tears. Sixteen of these patients had surgical confirmation of hamstring avulsion from the ischial tuberosity (14 conjoint, 2 biceps femoris alone) and all were reliably diagnosed with MR imaging (16/16), but less so with sonography (7/12). Four distal tendon avulsions were also observed (three semitendinosus, one biceps femoris). With respect to muscle injury, the biceps femoris was most commonly injured (124/154). Semimembranosus was an uncommon muscle injury (21/154) and semitendinosus rare (9/154). Imaging can discriminate a hamstring tendon avulsion from musculotendinous strain and helps identify which patients necessitate surgical management as opposed to conservative treatment.     

Treatment for ischial tuberosity avulsion fractures in adolescent athletes

Purpose

Avulsion fractures of the ischial tuberosity are rare sports injuries typically occurring in young athletes. Their misdiagnosis may lead to chronic pain or disability. The aim of this study is to report a retrospective series of patients sustaining a fracture of the ischial tuberosity and to propose decision guidelines.

Methods

The mechanism of accident, the diagnostic management, the mode of treatment and outcome after avulsion fractures of the ischial tuberosity in adolescents were analysed.

Results

Thirteen patients (1 female and 12 males) with a median age of 15 years (range 13–16 years) with an avulsion fracture of the ischial tuberosity were included. Twelve of these patients suffered from sports injuries leading to the avulsion fracture. Five of our patients with a displacement of >15 mm were treated operatively. The outcome was excellent in cases of acute presentation and osteosynthesis. Eight patients were treated conservatively: four of them showed a displacement of <15 mm and had an excellent outcome; and the other four patients had a displacement of >15 mm. Two of those patients had excellent outcome with regular bone healing, the remaining two patients developed pseudarthrosis associated with a good outcome.

Conclusion

The present paper shows that in patients with displacement of <15 mm, conservative treatment yields excellent results and early operative intervention should be considered in physically active patients with displacement of >15 mm.

Level of evidence

IV.     

Thoracic region pain in athletes

Pain in the thoracic region in athletes is more commonly from the thorax than from the thoracic spine. Although the thoracic spine is well protected from motion by the ribs, the chest wall and surrounding muscles are vulnerable to both overuse and acute injury in athletes. These injuries to muscle and bone include stress fractures, muscle strains, and avulsions. They are diagnosed primarily by history and physical examination. Bone scan is the most useful test if there is a question of a stress fracture. Most of these injuries respond to conservative treatment.     

The normal cervical spine and its variations on plain radiography and computed tomography

To detect abnormalities of the injured bony cervical spine, it is necessary to have a thorough knowledge of the normal cervical spine’s anatomy and its variations. It is the purpose of this article to emphasize the visual characteristics of the normal appearances in order to assist in the determination of whether the examination is normal or abnormal. Because of these visual characteristics, it is at times possible to be certain that the examination is normal solely on basis of the plain radiographs. On other occasions, because the plain radiographic appearance of normal and abnormal may overlap, further evaluation with computed tomography is necessary. Rarely, even with computed tomography, the appearance of normal, subacute injury, and acute injury may not be distinguishable.     

Computed tomographic diagnosis of a “midline package” of abdominal trauma: Two illustrative cases

A “midline package” of abdominal injuries may occur when the anterior mid-abdomen suffers direct blunt trauma. This package may include lacerations of the left lobe of the liver, pancreatic lacerations or fractures, and bowel injuries; if high in location, it may also be associated with sternal fractures and cardiac injuries. A common cause is motor vehicle accidents in which the driver suffers anterior abdominal compression from striking the steering wheel or steering column. Two cases are illustrated that were correctly diagnosed by abdominal computed tomography. The authors recommend an awareness of abdominal injury mechanisms and a knowledge of the expected combinations of abdominal injuries that may result.