A cohort study of one-year functional and radiographic outcomes following intra-articular distal radius fractures

BACKGROUND

The purpose of this study was to describe the outcomes of a series of patients followed prospectively after intra-articular distal radius fractures.

METHODS

One hundred forty-eight patients with intra-articular fractures (mean age, 47 years; age range, 44-54 years; gender distribution, 60 males and 88 females) were treated with cast only, arthroscopy/closed reduction plus pins, arthroscopy/closed reduction with external fixation, open reduction and internal fixation (ORIF) alone, and ORIF with external fixation according to surgeon preference and fracture characteristics. The 1-year outcomes across the groups were measured radiographically (n = 148) and functionally (n = 113; 1-year Wrist Outcome Measure score, Grip Strength, SF-36, and PRWE scores).

RESULTS

Radiographically, the groups had statistically significant differences in radial inclination, volar tilt, intra-articular step-off, and radial shortening in the pre-treatment X-rays. However, following treatment, treatment groups demonstrated no difference statistically in their follow-up radiographic measures. One-year PRWE scores were found to be statistically different across groups. Across groups, the ORIF-alone treatment group had the highest PRWE score reflecting greatest amount of pain and disability. One-year wrist outcome measure scores and grip strength scores were also found to be significantly different across treatment groups. The general health status as measured by the SF-36 was not found to be different across treatment groups.

CONCLUSIONS

These findings are consistent with treatment by indication; suboptimal ORIF outcomes may reflect older practice patterns with dorsal plating. A randomized control trial that compares treatments controlling for fracture severity and studies that develop formal clinical prediction rules for treatment assignment are needed.

Factors influencing the yield of mesenteric angiography in lower gastrointestinal bleed

AIM: To assess if certain triaging rules could be established to optimize the yield of mesenteric angiography.

METHODS: Medical records of 101 patients were retrospectively reviewed and parameters relating to age, gender, pulse rate, blood pressure, serum hemoglobin, intensive care unit (ICU) admission, and the number of packed red blood cells (PRBC) transfused in the 12 and 24 h prior to the angiography were tabulated in two groups with positive and negative angiography results.

RESULTS: We found no correlation between gender, pulse rate, blood pressure or serum hemoglobin and positivity of the mesenteric angiogram. But patients with positive angiogram were found to be on average 7 years older (73.2 years vs 65.9 years old) (P = 0.02). Angiogram was positive in 39.3 % (11/28) of patients admitted in ICU vs 23.2% (17/73) who were admitted elsewhere in the hospital (P = 0.03). In the 12 and 24 h prior to angiography, patients with a positive angiogram received a mean of 2.7 ± 2.3 and 3.3 ± 2.6 units of PRBC s respectively, while patients with a negative angiogram had a mean of 1.6 ± 1.9 (P = 0.02) and 2.1 ± 2.6 units (P = 0.04) received respectively in the same period.

CONCLUSION: Older age, ICU admission, having received at least 4 units PRBC over 12 h or 5 units over 24 h prior to angiogram are leading indicators for a positive study.

Radiographic imaging for traumatic ankle injuries: a demand profile and investigation of radiological reporting timeframes from an Australian tertiary facility

BACKGROUND

Radiographic examinations of the ankle are important in the clinical management of ankle injuries in hospital emergency departments. National (Australian) Emergency Access Targets (NEAT) stipulate that 90 percent of presentations should leave the emergency department within 4 hours. For a radiological report to have clinical usefulness and relevance to clinical teams treating patients with ankle injuries in emergency departments, the report would need to be prepared and available to the clinical team within the NEAT 4 hour timeframe; before the patient has left the emergency department. However, little is known about the demand profile of ankle injuries requiring radiographic examination or time until radiological reports are available for this clinical group in Australian public hospital emergency settings.

METHODS

This study utilised a prospective cohort of consecutive cases of ankle examinations from patients (n = 437) with suspected traumatic ankle injuries presenting to the emergency department of a tertiary hospital facility. Time stamps from the hospital Picture Archiving and Communication System were used to record the timing of three processing milestones for each patient's radiographic examination; the time of image acquisition, time of a provisional radiological report being made available for viewing by referring clinical teams, and time of final verification of radiological report.

RESULTS

Radiological reports and all three time stamps were available for 431 (98.6%) cases and were included in analysis. The total time between image acquisition and final radiological report verification exceeded 4 hours for 404 (92.5%) cases. The peak demand for radiographic examination of ankles was on weekend days, and in the afternoon and evening. The majority of examinations were provisionally reported and verified during weekday daytime shift hours.

CONCLUSIONS

Provisional or final radiological reports were frequently not available within 4 hours of image acquisition among this sample. Effective and cost-efficient strategies to improve the support provided to referring clinical teams from medical imaging departments may enhance emergency care interventions for people presenting to emergency departments with ankle injuries; particularly those with imaging findings that may be challenging for junior clinical staff to interpret without a definitive radiological report.

The palmar metric: A novel radiographic assessment of the equine distal phalanx

Digital radiographs are often used to subjectively assess the equine digit. Recently, quantitative and objective radiographic measurements have been reported that give new insight into the form and function of the equine digit. We investigated a radio-dense curvilinear profile along the distal phalanx on lateral radiographs we term the Palmar Curve (PC) that we believe provides a measurement of the concavity of the distal phalanx of the horse. A second quantitative measurement, the Palmar Metric (PM) was defined as the percent area under the PC. We correlated the PM and age from 544 radiographs of the distal phalanx from the left and right front feet of various breed horses of known age, and 278 radiographs of the front feet of Quarter Horses. The PM was negatively correlated with age and decreased at a rate of 0.28 % per year for horses of various breeds and 0.33 % per year for Quarter Horses. Therefore, veterinarians should be aware of age related change in the concave, parietal solar aspect of the distal phalanx in the horse.

Avulsion of the greater trochanter and craniodorsal luxation of the hip joint in a cat: importance of precise radiographic evaluation

A traumatic coxofemoral luxation was diagnosed in a 15-month-old European neutered male cat, and on the basis of the radiographic evaluation a closed reduction was performed. Consequently, the cat was presented at the University of Bologna because of the failure of the treatment. A supplementary radiographic exam revealed the concomitant avulsion of the greater trochanter, consequently surgical management of the coxofemoral luxation was attempted successfully. Therefore, correct planning of the radiographic examination should be considered to prevent possible mistakes.

Impact of body mass index on the detection of radiographic localized pleural thickening

RATIONALE AND OBJECTIVES

Subpleural fat can be difficult to distinguish from localized pleural thickening (LPT), a marker of asbestos exposure, on chest radiographs. The aims of this study were to examine the influence of body mass index (BMI) on the performance of radiograph readers when classifying LPT and to model the risk of false test results with varying BMI.

MATERIALS AND METHODS

Subjects (n = 200) were patients being screened or treated for asbestos-related health outcomes. A film chest radiograph, a digital chest radiograph, and a high-resolution computed tomography (HRCT) chest scan were collected from each subject. All radiographs were independently read by seven B readers and scored using the International Labour Office system. HRCT scans, read by three experienced thoracic radiologists, served as the gold standard for the presence of LPT. We calculated measures of radiograph reader performance, including sensitivity and specificity, for each image modality. We also used logistic regression to estimate the probability of a false-positive and a false-negative result while controlling for covariates.

RESULTS

The proportion of false-positive readings correlated with BMI. While controlling for covariates, regression modeling showed the probability of a false-positive result increased with increasing BMI category, younger age, not having pleural calcification, and among subjects not reporting occupational or household contact asbestos exposure.

CONCLUSIONS

Clinicians should be cautious when evaluating radiographs of younger obese persons for the presence of asbestos-related pleural plaque, particularly in populations having an anticipated low or background prevalence of LPT.

Differences between X-ray and MRI-determined knee cartilage thickness in weight-bearing and non-weight-bearing conditions

OBJECTIVE

Determine the effect of loading upon MRI-based mean medial femorotibial cartilage thickness (mMFT_th) and radiograph-based minimum joint space width (mJSW), and determine loading's effect on the relationship between these measures.

METHODS

MRI and radiographs were analyzed of 25 knees in weight-bearing and non-weight-bearing conditions. Eight subjects had a Kellgren-Lawrence (KL) grade of 0, indicating no evidence of radiographic OA. The rest were KL = 2 or KL = 3, indicating mild to moderate OA. The change from unloaded to loaded conditions was calculated.

RESULTS

Joint space measures decreased from unloaded to loaded conditions for both radiographs (mJSW = 3.29 mm unloaded to 3.16 mm loaded, P < 0.05) and MRI (mMFT_th = 2.70 mm unloaded to 2.55 mm loaded P < 0.001). The mean absolute difference measured from radiographs was larger for the OA group than the control group, at -0.20 mm for OA vs +0.01 mm for control. Loaded X-ray and loaded MRI joint space values from our study were no better correlated to one another than loaded X-ray and unloaded MRI.

CONCLUSION

Knee loading does not add a very significant value to the study of joint space on healthy knees, but loading may play a role in the study of OA knees. Unloaded MRI assessments of cartilage thickness are as correlated to loaded JSW as to loaded MRI measurements. More study is necessary to determine whether loaded MRI adds significant value to the study of OA progression.

A plain abdominal radiograph diagnosis of appendicitis

INTRODUCTION

Despite reported poor sensitivity and specificity, plain abdominal radiographs have a role in the investigation of suspected appendicitis.

PRESENTATION OF CASE

We report a case of a previously healthy 47 year old man, who presented with sudden onset abdominal pain associated with a raised temperature. He gave a short history of pain around the umbilicus, which radiated to his right iliac fossa over a period of hours. On examination his abdomen was soft with rebound tenderness in the right iliac fossa. Investigations revealed white cell count 11.2 × 109/L, CRP 4 mg/L and normal haemoglobin, renal and liver function tests. An inflamed appendix was visible with thickened walls on a plain abdominal radiograph and was confirmed during laparoscopic appendectomy and subsequent histology. He made good recovery and was discharged.

DISCUSSION

Prominent appendiceal wall and air in the appendix has been described in the literature as a CT finding that can distinguish appendicitis from other differential diagnoses and here we present a case of diagnosis of appendicitis on a plain abdominal radiograph showing this sign which to the best of our knowledge is rarely seen on abdominal films.

CONCLUSION

Careful assessment of plain abdominal films in suspected appendicitis is encouraged not just for exclusion of other causes of pain but also in the possible detection of an inflamed appendix.

Utility of week one radiographs post total hip arthroplasty

INTRODUCTION

We retrospectively analysed 129 consecutive patients who underwent hip arthroplasty at a university-affiliated hospital in Melbourne, Australia between February and September 2011 with respect to the quality of the week one radiographs, placement of the prosthesis and the presence of a peri-prosthetic fracture or dislocation.

METHOD

Patient records and radiographs were reviewed to ascertain whether a deviation in routine management occurred based on the information obtained from week one post-operative radiographs.

RESULTS

116 of the 129 patients met the inclusion criteria for the study. 115 patients underwent routine week one hip radiographs with a mean time after surgery of 2.5 days. 89 (77%) of these patients had radiographs with a typical post-operative appearance. 26 (23%) had radiographs with an atypical appearance defined by the presence of one or more of the following: offset difference of >10 mm (11%), leg length difference of >10 mm (11%), sub-optimal acetabular component inclination of <30° or >50° (9%), sub-optimal femoral stem position of >5° varus or valgus (2%), sub-optimal femoral Greun cement distribution of 2 or more absent zones (2%), cement extrusion (1%), peri-prosthetic fracture (0) or dislocation (0). None of the routine week one radiographs resulted in a change in early post-operative management. 1 patient underwent non-routine, immediate post-operative radiographs.

DISCUSSION

Our study did not demonstrate a case where deviation from standard clinical pathways occurred as a result of routine post-operative radiographs. A higher power study would help the established surgeon to determine whether post-operative radiographs could be performed at a more comfortable and convenient time such as the outpatient setting.

Development of a plain radiograph requesting algorithm for patients presenting with acute abdominal pain

Radiologists at a large teaching hospital felt that plain radiograph imaging was being performed inappropriately for patients admitted with acute abdominal pain. They felt requests were either not indicated or CT was a more appropriate first line radiological investigation in certain circumstances.An audit was performed looking at plain radiograph imaging requests for emergency admissions under general surgery, using Royal College of Radiologists (RCR) guidelines as the standard. The audit revealed that only 80% of plain radiograph requests met RCR guidelines. It also showed that 33% of acute admissions undergoing plain radiograph imaging proceeded to CT within forty-eight hours. These findings lead to the development of a plain radiograph algorithm. This aimed to improve plain radiograph imaging requests and to increase the use of CT as an earlier or first line radiological investigation where appropriate.Outcome of discussion at local and regional clinical governance meetings was that earlier CT would be useful in specific circumstances. The algorithm provides a framework for appropriately expediting CT in patients presenting with acute abdominal pain where bowel obstruction or perforation was suspected. However, consultant surgeons felt that in patients presenting with acute abdominal pain, the plain abdominal radiograph often demonstrates findings associated with specific diagnoses not specifically indicated by RCR guidelines. If RCR guidelines for plain radiograph imaging are broadened, radiological interpretation would examine for a broader range of findings and, when combined with other clinical information, diagnoses can be made, thus avoiding the need for further imaging or explorative surgery.

Esophageal space-occupying lesion caused by Ascaris lumbricoides

Ascaris lumbricoides is the largest intestinal nematode parasite of man, which can lead to various complications because of its mobility. As the esophagus is not normal habitat of Ascaris, the report of esophageal ascariasis is rare. An old female presented with dysphagia after an intake of several red bean buns and haw jellies. The barium meal examination revealed a spherical defect in the lower esophagus. Esophageal bezoar or esophageal carcinoma was considered at the beginning. The patient fasted, and received fluid replacement treatment as well as some oral drugs such as proton pump inhibitor and sodium bicarbonate. Then upper gastrointestinal endoscopy was done to further confirm the diagnosis and found a live Ascaris lumbricoides in the gastric antrum and two in the duodenal bulb. The conclusive diagnosis was ascariasis. The esophageal space-occupying lesion might be the entangled worm bolus. Anthelmitnic treatment with mebendazole improved patient’s clinical manifestations along with normalization of the radiological findings during a 2-wk follow-up. Authors report herein this rare case of Ascaris lumbricoides in the esophagus, emphasizing the importance of awareness of this parasitic infection as it often presents with different and unspecific symptoms.

Radiographic assessment of hips in patients with spinal cord injury

OBJECTIVE

The spinal cord-injured patients begin to present a new configuration of forces on the joints. The hip joint is one of the most affected, because these patients generally use a wheelchair as a means of locomotion. Osteoarticular changes, such as heterotopic ossification, can be found in these patients, as evidenced by radiographic studies. This study aims to identify radiographic changes in hips of spinal cord-injured patients.

METHODS

15 patients (30 hips) were evaluated and followed up at the Laboratory of Biomechanical Rehabilitation of the Musculoskeletal System of HC-Unicamp, through the analysis of radiographs of the pelvis in anterior-posterior and Lowenstein lateral positions.

RESULTS

Of the total hips, only seven (23%) had no evidence of articular damage. The prevalence of heterotopic ossification found (16.6%) was similar to the literature.

CONCLUSION

The radiographic assessment of these patient's hips is justified by the prevalence of joint changes found. Level of Evidence II, Development of diagnostic criteria in consecutive patients (with universally applied reference "gold" standard).

Where does it lead? Imaging features of cardiovascular implantable electronic devices on chest radiograph and CT

Pacemakers and implantable cardioverter defibrillators (ICDs) are being increasingly employed in patients suffering from cardiac rhythm disturbances. The principal objective of this article is to familiarize radiologists with pacemakers and ICDs on chest radiographs and CT scans. Therefore, the preferred lead positions according to pacemaker types and anatomic variants are introduced in this study. Additionally, the imaging features of incorrect lead positions and defects, as well as complications subsequent to pacemaker implantation are demonstrated herein.

Quality of root canal fillings performed by undergraduate dental students

OBJECTIVES

The purpose of this study was to evaluate the radiographic quality of root canal fillings performed by first and second clinical year dental students at the Faculty of Dentistry in Süleyman Demirel University, Turkey.

METHODS

The technical quality of 833 root canal fillings was evaluated by three examiners according to the density of the filling and the distance between the end of the filling and the radiographic apex. A root canal with acceptable filling length and homogeneous root filling was defined as being good quality endodontic work (GQEW). A treated tooth was defined as having good quality endodontic work tooth (GQEW-T) when all its canals had a GQEW rating.

RESULTS

A Chi-square (χ(2)) test at the 0.05 significance level was used for the statistical analysis of the data. Of a total of 833 root canals, 662 (79.47%) root fillings were classed as GQEW. Two hundred fifty canals (73.4%) (135 teeth) treated by first clinical year dental students were defined as GQEW-T while 412 canals (204 teeth) (73.9%) treated by second clinical year dental students were defined as GQEW-T (P>.05). Most of the GQEW-T were defined in anterior teeth (90.1%), whereas the fewest were in molar teeth (46.6%) for both first and second clinical year dental students (P<.001).

CONCLUSIONS

The quality of root canal fillings in anterior teeth performed by undergraduate dental students in Isparta, Turkey was satisfactory. However, to improve the success with molar teeth, education about newer techniques and instruments must be incorporated into the preclinical and clinical curriculum.

The development of a clinical decision making algorithm for detection of osteoporotic vertebral compression fracture or wedge deformity

The clinical diagnosis of an osteoporotic vertebral compression fracture (OVCF) is challenging and requires detailed assessment using comprehensive imaging methods. Further complicating matter is that the clinical sequelae associated with OVCF typically involves asymptomatic findings and variable pain patterns. The purpose of this study was to identify clinical characteristics and assessment findings that were associated with a diagnosis of OVCF. The study evaluated routine clinical findings in over 1400 subjects seen at an adult spine surgery clinic for thoracolumbar spine-related conditions within the years 2005-2009. All patients underwent a standardized clinical examination that included a self-report, observational, physical examination and imaging assessment. The diagnosis of OVCF was made after assessment of radiographic findings in sagittal alignment, vertebral body compression, and spinal canal dimensions. Data from the patient history and observational findings were then statistically analyzed and compared between those patients with a diagnosis of OVCF and those with an alternative diagnosis. Based on the results, a diagnostic support tool was created to predict the likelihood of OVCF. The most diagnostic combination included a cluster of: (1) age > 52 years; (2) no presence of leg pain; (3) body mass index ⩽ 22; (4) does not exercise regularly; and (5) female gender. A finding of two of five positive tests or less demonstrated high sensitivity of 0.95 (95% CI  =  0.83-0.99) and low negative likelihood ratio of 0.16 (95% CI  =  0.04-0.51), providing moderate value to rule out OVCF. Four of five yielded a positive likelihood ratio (LR+) of 9.6 (95% CI  =  3.7-14.9) providing moderate value in ruling in the diagnosis of OVCF. Further validation is necessary prospectively to determine the value of these findings on a disparate sample of patients in other unique environments.

Use of chest sonography in acute-care radiology()

Diagnosis of acute lung disease is a daily challenge for radiologists working in acute-care areas. It is generally based on the results of chest radiography performed under technically unfavorable conditions. Computed tomography (CT) is undoubtedly more accurate in these cases, but it cannot always be performed on critically ill patients who need continuous care.The use of thoracic ultrasonography (US) has recently been proposed for the study of acute lung disease. It can be carried out rapidly at the bedside and does not require any particularly sophisticated equipment. This report analyzes our experience with chest sonography as a supplement to chest radiography in an Emergency Radiology Unit. We performed chest sonography - as an adjunct to chest radiography - on 168 patients with acute chest pathology. Static and dynamic US signs were analyzed in light of radiographic findings and, when possible, CT. The use of chest US improved the authors' ability to provide confident diagnoses of acute disease of the chest and lungs.

Technical quality of root canal treatment performed by undergraduate dental students

INTRODUCTION

This study was carried out to evaluate the technical quality of root canal treatment (RCT) performed by undergraduate dental students at the Islamic Azad University in Tehran, Iran.

MATERIALS AND METHODS

Four-hundred records of patients who had received RCT at faculty of dentistry, between the years 2004-2006 were evaluated. For each treated tooth at least three periapical x-rays were assessed: preoperative, working length measurement, and postoperative. Evaluation of root canal filling was based on two variables: length and density. The filling length was recorded as adequate, under- or overfilled. Density of filling was recorded as poor or adequate. Fillings with adequate length and density were recorded as acceptable. Detected iatrogenic errors were: ledge formations, root perforations, furcation perforations, strip perforations and presence of fractured instruments. Results were evaluated statistically using one-way ANOVA and Chi-square analysis.

RESULTS

Out of the 400 teeth, 50.5% had at least one of the mentioned errors. Acceptable filling was observed in 32.5% of all studied teeth. Ledge was found in 17.5% of the teeth. Canal curvature was the most important factor associated with ledge formation (P<0.05).

CONCLUSION

The technical quality of RCT performed by undergraduate dental students using step-back preparation and cold lateral condensation was classified as acceptable in 32.5% of the cases.