ACR Appropriateness Criteria® Acute Trauma to the Foot

The missed chapter on midfoot: Chopart injuries

PURPOSE

Midtarsal injuries are often missed at initial presentation which may lead to long-term complications. Nonetheless, radiographs (XR) are used as a primary imaging method. The place of cone beam computer tomography (CBCT) remains unclear in the management of midfoot injuries. The aim of this study was to update imaging findings on traumatic ankle and foot injuries (TAAFI) with CBCT and to assess the sensitivity, specificity and accuracy of XR compared to CBCT for midfoot injuries detections.

MATERIAL AND METHODS

All CBCT studies performed due to (TAAFI) that had previous XR were collected for a period of 5 years. They were retrospectively anonymized and analyzed by a radiologist. A second blinded study of XR was made by a second radiologist as a control.

RESULTS

A total of 754 cases were included. Lisfranc and Chopart injuries were detected in 153 (20.2%) and 154 (20.4%) patients, respectively. Lisfranc and Chopart's lesions combined together were seen in 33 cases (10.7%). A blinded retrospective analysis of XR compared to CBCT shows a sensitivity of 64.9% (56.8-72.4%; 95% CI), a specificity of 95.0% (92.9-96.6%; 95% CI) and an accuracy of 88.9% (86.4-91.0%; 95% CI) for Chopart's injuries. Regarding Lisfranc, the sensitivity was 62.1% (53.9-69.8%; 95% CI), specificity 99.0% (97.8-99.6%; 95% CI) and accuracy 91.5% (89.3-93.4%; 95% CI).

CONCLUSION

This cohort study highlights the missed injuries of Chopart on XR and the low association with Lisfranc avulsions. The use of CBCT helps in detecting and assessing midfoot injury.

Physical therapist awareness of diagnostic imaging referral jurisdictional scope of practice: an observational study

OBJECTIVES

To examine physical therapist awareness and utilization of imaging referral privileges in the United States (US) and how it relates to direct access frequency.

METHODS

This study utilized survey data collected in 2020-2021 from US physical therapists. Subjects were asked about imaging referral jurisdictional authority in their state. Responses were analyzed for accuracy and compared to the level of jurisdictional authority and its impact on imaging referral. Analysis of imaging skills performance and imaging referral practices were compared to direct access frequency.

RESULTS

Only 42.0% of physical therapists practicing in states that allow imaging referral were aware of this privilege. Those practicing where imaging referral was allowed via state legislation were significantly more likely (p < 0.01) to be aware of this privilege (71.4%) compared to those granted by the state board (25.2%). Those aware of their imaging referral scope were more likely (p < 0.01) to practice imaging referral (44.5%) compared to those who were unaware (3.2%). Direct access frequency was positively associated with imaging skill performance and imaging referral practice (p < 0.01). Doctors of Physical Therapy, residency/fellowship-trained physical therapists, and board-certified physical therapists all reported practicing greater frequency of direct access (p < 0.01).

DISCUSSION/CONCLUSION

There is a striking lack of awareness of imaging privileges among physical therapists as influenced by the level of jurisdictional scope. These results suggest that the lack of awareness may have a dampening effect on diagnostic imaging referrals. The American Physical Therapy Association should consider engaging with state boards to raise imaging privilege awareness.

Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance

PURPOSE

Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings.

METHODS

This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem-Intervention/Indicator-Comparator-Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria.

RESULTS

Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging.

CONCLUSION

These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.

Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.

Paediatric sand toe: radiographic, ultrasound and MRI findings of dorsomedial capsular injury

Hyperflexion injury to the metatarsophalangeal joint of the great toe, referred to as sand toe, can cause significant functional impairment. To our knowledge, there have been no radiological descriptions of this injury in the paediatric age group. Here, we report radiographic, sonographic and MRI findings in a male paediatric patient who sustained a sand toe injury, highlighting structural damage to the dorsomedial capsule and medial sagittal band, and discuss sand toe's favourable prognosis with conservative management.

Inconsistent radiographic diagnostic criteria for lisfranc injuries: a systematic review

PURPOSE

To evaluate the radiographic diagnostic criteria and propose standardised radiographic criteria for Lisfranc injuries.

METHODS

A systematic review of the PubMed and Embase databases was performed according to the PRISMA guidelines. The various radiographic criteria for the diagnosis of Lisfranc injuries were extracted. Descriptive statistics were presented for all continuous (as mean ± standard deviation) and categorical variables (as frequencies by percentages).

RESULTS

The literature search included 29 studies that totalled 1115 Lisfranc injuries. The risk of bias ranged from "Low" to "Moderate" risk according to the ROBINS-I tool. The overall recommendations according to the GRADE assessment ranged from "Very Low" to "High". 1st metatarsal to 2nd metatarsal diastasis was the most common of the 12 various radiographic diagnostic criteria observed, as was employed in 18 studies. This was followed by 2nd cuneiform to 2nd metatarsal subluxation, as was employed in 11 studies.

CONCLUSION

The radiographic diagnostic criteria of Lisfranc injuries were heterogeneous. The proposition for homogenous radiographic diagnostic criteria is that the following features must be observed for the diagnosis of Lisfranc injuries: 1st metatarsal to 2nd metatarsal diastasis of ≥ 2 mm on anteroposterior view or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior or oblique views. Further advanced imaging by CT or MRI may be required in patients with normal radiographs but with continued suspicion for Lisfranc injuries.

LEVEL OF EVIDENCE

4, systematic review.

Ultrasound versus magnetic resonance imaging of soft-tissue lesions: competitive or complementary?

Soft-tissue lumps and bumps are a common referral for imaging in children and adolescents. The etiology of these lesions includes benign non-tumorous lesions, as well as benign and malignant tumors. Some of these lesions have a characteristic imaging appearance but others do not and require tissue sampling to make a diagnosis. MRI typically provides the best overall characterization of soft-tissue masses; however, in some cases US provides complementary information to that provided by MRI that can help make a diagnosis.