Multislice CT in imaging of trauma of the spine, pelvis and complex foot injuries

Accuracy of Palpation Procedures for Locating the C1 Transverse Process and Masseter Muscle as Confirmed by Computed Tomography Images

OBJECTIVE

The purpose of this study was to examine the accuracy of palpation methods for locating the transverse processes of the first cervical vertebra and masseter muscle using radiographic images as the gold-standard method and the association between personal characteristics with the observed accuracy.

METHODS

This was a single-blinded, diagnostic accuracy study. Ninety-five participants (49 women, 58 ± 16 years of age) were enrolled in this study. A single examiner palpated the neck and face region of all participants to identify the transverse processes of the first cervical vertebra and masseter muscles bilaterally. In sequence, participants underwent a multislice computed tomography scan for assessment of the superimposed inner body structure. Two radiologists assessed the computed tomography images using the same criteria and were blinded regarding each other's assessment and the anatomic landmarks under investigation. The palpation accuracy was calculated as the proportion of the correctly identified landmarks in the studied sample. The correlation of the palpation outcome (correct = 1; incorrect = 0) with age, sex (male = 1; female = 0), and body mass index was investigated using the point-biserial correlation coefficient.

RESULTS

The right and left transverse processes were correctly located in 76 (80%) and 81 (85%) participants, respectively, and bilaterally in 157 events (83%), as evaluated by the consensus of the 2 radiologists. The masseter muscles were correctly localized bilaterally in 95 of 95 (100%) participants. Body mass showed statistical evidence of a weak, positive correlation with the correct location of the transverse processes of the first cervical vertebra at the right body side (r = .219; 95% confidence interval, 0.018-0.403; P = .033).

CONCLUSION

Palpation methods used in this study accurately identified the location of the first cervical vertebra spinous processes and the masseter muscles.

ACR Appropriateness Criteria® Acute Trauma to the Foot

Acute injuries to the foot are frequently encountered in the emergency room and in general practice settings. This publication defines best practices for imaging evaluations for several variants of patients presenting with acute foot trauma. The variants include scenarios when the Ottawa rules can be evaluated, when there are exclusionary criteria, and when suspected pathology is in anatomic areas not addressed by the Ottawa rules. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Evidence-based anatomical review areas derived from systematic analysis of cases from a radiological departmental discrepancy meeting

AIM

To produce short checklists of specific anatomical review sites for different regions of the body based on the frequency of radiological errors reviewed at radiology discrepancy meetings, thereby creating "evidence-based" review areas for radiology reporting.

MATERIALS AND METHODS

A single centre discrepancy database was retrospectively reviewed from a 5-year period. All errors were classified by type, modality, body system, and specific anatomical location. Errors were assigned to one of four body regions: chest, abdominopelvic, central nervous system (CNS), and musculoskeletal (MSK). Frequencies of errors in anatomical locations were then analysed.

RESULTS

There were 561 errors in 477 examinations; 290 (46%) errors occurred in the abdomen/pelvis, 99 (15.7%) in the chest, 117 (18.5%) in the CNS, and 125 (19.9%) in the MSK system. In each body system, the five most common location were chest: lung bases on computed tomography (CT), apices on radiography, pulmonary vasculature, bones, and mediastinum; abdominopelvic: vasculature, colon, kidneys, liver, and pancreas; CNS: intracranial vasculature, peripheral cerebral grey matter, bone, parafalcine, and the frontotemporal lobes surrounding the Sylvian fissure; and MSK: calvarium, sacrum, pelvis, chest, and spine.

CONCLUSION

The five listed locations accounted for >50% of all perceptual errors suggesting an avenue for focused review at the end of reporting.

Retrospective analysis of whole-body multislice computed tomography findings taken in trauma patients

Objectives

Using whole-body multislice computed tomography (MSCT) excessively or with irrelevant indications can be seen in many centers. The aim of this study was to analyze retrospectively the MSCT findings in trauma patients admitted to the emergency department.

Methods

Records of the patients who have applied to the emergency department due to blunt trauma in a 12 month period and whose whole body MSCT images have been taken, were evaluated using the “Nucleus Medical Information System”.

Results

The most frequent type of trauma was traffic accidents in 61.4%, falling down from the height in 22.4%, and motorcycle accidents in 11.4% of patients. Of the patients, 25.2% were discharged from the emergency, while 73.8% were hospitalized. At least one CT findings associated with trauma was present in 61.4% of our patients. Pathological findings in MSCT were most frequently detected in the head and face (35.3%) and thoracic (28.6%) regions, respectively. The most common finding in the head and face region was fractures. The most common pathological findings in the thoracic region were pulmonary contusion and rib fractures. A significant relationship was detected between trauma type and spinal MSCT result (p < 0.001). In a large percentage of the patients, MSCT findings were normal in the abdominal region and genitourinary system. Vertebral fractures were most frequently detected in the thoracolumbar region.

Conclusions

In our study, our rate of negative CT was found to be 38.6%, which is a higher ratio compared to other studies conducte on this topic.

Intravenous bisphosphonates and vitamin D in the treatment of bone marrow oedema in professional athletes

INTRODUCTION

The goal of this retrospective study was to evaluate the safety and efficacy of ibandronate for bone marrow oedema (BMO) syndrome and stress fracture cases, and to demonstrate an additional field of therapeutic importance-the high-performance athlete.

PATIENTS AND METHODS

This retrospective study included twenty-five high-performance athletes. Sixty per cent of the athletes were European soccer players and 40.0% other high-class international athletes (3 women and 22 men with an average age of 25.0±4.2), with BMO of the lower trunk or extremity diagnosed by magnetic resonance imaging (MRI). The treatment regimen consisted of high-dose vitamin D supplementation and intravenous ibandronate therapy.

RESULTS

The time between the onset of pain and proper diagnosis of BMO was 106.3±104.1 days. Excellent pain reduction (pain at rest and under strain) and improved mobility was reported within the first two weeks after the first ibandronate administration by sixteen patients (64%). The time from first treatment until return to competition (RTC) was on average 102.6±65.2 days in total. If the time from onset of pain until diagnosis was within 40 days, the RTC was significantly reduced (p≤0.05) to almost 50% (63.8±48.1 days) when compared to the athletes with later diagnosis (124.4±63.2 days).

CONCLUSIONS

The here-applied therapy regimen of intravenous BPs application and vitamin D supplementation in BMO syndrome has a beneficial effect for high-performance athletes. An early diagnosis and rapid treatment start can reduce the RTC significantly. An optimal bone metabolism with sufficient daily calcium and vitamin D intake is crucial and should not only be strived for the professional but also for the recreational athlete.

The role of early multislice computed tomography in major trauma

Whole-body multislice spiral computed tomography (MSCT) has become a very important dignostic tool in the management of patients with multiple injuries. Many reports exist which demonstrate the feasibility and the benefit when using whole-body MSCT in the early phase of in-hospital management of trauma patients. Even in hemodynamically instable patients (except cardiac arrest), whole-body MSCT can be used and is a safe diagnostic procedure. While the diagnostic superiority of multislice computed tomography is proven for different organ regions (e.g. head/brain, chest, abdomen, pelvis and spine), its use as a single whole-body scan is still part of an ongoing discussion. Especially concerns about radiation exposure are the reason for uncertainty about when using whole-body trauma scan. Predefined scan protocols and individual positioning of patients may help to keep radiation dose as minimal as possible. To justify higher radiation dose, the indication must be chosen appropriately. Therefore, the use of a sensitive and specific triage scheme seems to be reasonable. Overscanning patients with minor trauma needs to be avoided, while the benefit for patients with severe multiple injuries is obvious.

Combined pubic rami and sacral osteoporotic fractures: a prospective study

Background

Pelvic osteoporotic fractures (POFs) are often associated with considerable morbidity and mortality mainly as a result of infections and cardiovascular events. Patients usually need prolonged institutionalization, rehabilitation, and follow-up, with a high rate of dependency and cost. The most common sites of POFs include the pubic rami, sacrum, ilium, and acetabulum. Combined pubic rami (PROFs) and sacral osteoporotic fractures (SOFs) have been reported, mostly in retrospective studies, describing the mechanism of injury and incidence. The aim of this study was to evaluate the association between PROFs and SOFs and to assess the effect of combined PROFs and SOFs on patients’ mobility, discharge destination, and length of stay.

Materials and methods

We prospectively studied 67 patients with low-impact PROFs and/or SOFs. There were 54 (80.4%) female and 13 (19.6%) male patients, and the average age was 87.5 (range 65–96) years. All patients were assessed by the fracture liaison service. Patients had magnetic resonance imaging or bone scan when there was history of low back pain following the injury or lumbosacral tenderness on clinical examination.

Results

The mean length of stay for all patients was 45 (±35) days. Mortality rate was 10.4%. A significant relationship was found between low back pain and a positive finding of sacral fracture. Patients with combined PROFs and SOFs showed significantly longer length of stay than those with isolated PROFs.

Conclusions

The presence of low back pain and tenderness in patients who had low-impact pelvic injuries was highly suggestive of the presence of an associated SOF. There was a high association between sacral and PROFs. The length of stay of patients with PROFs associated with sacral osteoporotic fractures was significantly longer than that of patients with PROFs only. Therefore, we recommend considering the high association between SOFs and PROFs in planning the management and rehabilitation of patients with POFs.

[Applications of multidetector computed tomography in limb trauma]

Multidetector computed tomography (MDCT) has significant advantages over plain-film X-rays in the study of the extremities. Acute trauma poses diagnostic challenges, especially in joints in which the overlapping of bony structures impedes the view of the fractures or luxations. Each major joint has at least one classification system for fractures that aims to include the fundamental aspects necessary to orient the most effective treatment. These are the cases in which MDCT's capabilities for multiplanar and three-dimensional reconstructions provide information that is crucial for the management of trauma to the joint.

Medial fracture line significance in calcaneus fracture

In Sanders' classification of calcaneus fractures, the medial fracture line (subtype C) is close to the tarsal canal, which contains an artery for the talus and calcaneus. We hypothesized that because of this brittle vascular localization, patients with C line fracture patterns might describe radiologic subtalar arthritis more often and have more complaints. The purpose of the present study was to compare the results of C line fracture patterns with other types of calcaneus fractures. A total of 25 surgically treated feet were involved. Regarding Sanders' classification, group 1 included fractures involving the C line (11 feet), and group 2 included fractures not involving the C line (14 feet). Patient age at admission, trauma date, and interval until surgery were obtained from the patients' medical records. The Bohler angles were determined from the radiographs. At the last follow-up visit, the radiologist graded subtalar arthritis using computed tomography. For clinical follow-up, the American Orthopaedic Foot and Ankle Society and Maryland scores were assessed. No significant differences were found in mean age, follow-up period, delay to surgery, or postoperative Bohler angle between the 2 groups. The mean preoperative Bohler angle was significantly low for group 1. Although not significantly different, the mean American Orthopaedic Foot and Ankle Society and Maryland scores were lower for group 1 (81.9 and 84.3) than group 2 (87.8 and 92.0), and the median subtalar arthritis grade was greater for group 1 (score 2) than for group 2 (score 1.5). The worse results with C line fracture patterns despite satisfactory reduction might result from sinus tarsi artery damage. Angiographic investigations could clarify this theory in the future. Consequently, surgeons must inform and should hesitate to operate on patients with these highly comminuted C line calcaneus fractures.

[Polytrauma management in a period of change: time analysis of new strategies for emergency room treatment]

BACKGROUND

Quality management and the early implementation of whole-body multi-slice spiral computed tomography (whole-body MSCT) are becoming increasingly important in the management of patients with multiple trauma. The aim of this study was to evaluate both components with respect to the time factor for treatment.

METHODS

The investigation involved a retrospective data analysis of the time needed in the emergency room for the initial stabilization (phase A), completing the diagnosis (phase B) and the emergency room treatment (phase C). The investigation included three groups: trauma patients imaged in the emergency room with conventional imaging procedures (group I), with whole-body MSCT alone (group II) and those who were imaged with whole-body MSCT after the introduction of a quality management system with standard operating procedures (group III).

RESULTS

The times for resuscitation (phase A), for diagnostic evaluation (phase B) and for total treatment (phase C) were analyzed. The times for phase A were for group I (n=79) 10 min (interquartile range, IQR 8-12 min), group II (n=82) 13 min (IQR 10-17 min) and group III (n=79) 10 min (IQR 8-15 min; p<0.001). The times for phase B were 70 min (IQR 56-85 min) for group I, 23 min (IQR 17-33 min) for group II and 17 min (IQR 13-21 min; p<0.001) for group III. For phase C the times were 82 min (IQR 66-110 min) for group I, 47 min (IQR 37-59 min) for group II and 42 min (IQR 34-52 min; p<0.05) for group III.

CONCLUSION

Quality management and the early implementation of whole-body MSCT can accelerate the treatment work flow. A rapid initial diagnosis represents an important component in the high quality of treatment of polytrauma patients.

Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study

BACKGROUND

The number of trauma centres using whole-body CT for early assessment of primary trauma is increasing. There is no evidence to suggest that use of whole-body CT has any effect on the outcome of patients with major trauma. We therefore compared the probability of survival in patients with blunt trauma who had whole-body CT during resuscitation with those who had not.

METHODS

In a retrospective, multicentre study, we used the data recorded in the trauma registry of the German Trauma Society to calculate the probability of survival according to the trauma and injury severity score (TRISS), revised injury severity classification (RISC) score, and standardised mortality ratio (SMR, ratio of recorded to expected mortality) for 4621 patients with blunt trauma given whole-body or non-whole-body CT.

FINDINGS

1494 (32%) of 4621 patients were given whole-body CT. Mean age was 42.6 years (SD 20.7), 3364 (73%) were men, and mean injury-severity score was 29.7 (13.0). SMR based on TRISS was 0.745 (95% CI 0.633-0.859) for patients given whole-body CT versus 1.023 (0.909-1.137) for those given non-whole-body CT (p<0.001). SMR based on the RISC score was 0.865 (0.774-0.956) for patients given whole-body CT versus 1.034 (0.959-1.109) for those given non-whole-body CT (p=0.017). The relative reduction in mortality based on TRISS was 25% (14-37) versus 13% (4-23) based on RISC score. Multivariate adjustment for hospital level, year of trauma, and potential centre effects confirmed that whole-body CT is an independent predictor for survival (p </= 0.002). The number needed to scan was 17 based on TRISS and 32 based on RISC calculation.

INTERPRETATION

Integration of whole-body CT into early trauma care significantly increased the probability of survival in patients with polytrauma. Whole-body CT is recommended as a standard diagnostic method during the early resuscitation phase for patients with polytrauma.

FUNDING

None.

Whole-body multislice computed tomography as the first line diagnostic tool in patients with multiple injuries: the focus on time

OBJECTIVE

Whole-body multislice helical computed tomography (MSCT) becomes increasingly important as a diagnostic tool in patients with multiple injuries. We describe time requirement of two different diagnostic approaches to multiple injuries one with whole-body-MSCT (MSCT Trauma-Protocol) as the sole radiologic procedure and one with conventional use of radiography, combined with abdominal ultrasound and organ focused CT (Conventional-Trauma-Protocol).

METHODS

Observational study with retrospective analysis of time requirements for resuscitation, diagnostic workup and transfer to definitive treatment after changing from conventional to MSCT Trauma-Protocol. Group I: data from trauma patients imaged with whole-body MSCT. Group II: data of trauma patients investigated with conventional trauma protocol before the introduction of MSCT-Trauma-Protocol.

RESULTS

The complete diagnostic workup in group I (n = 82) was finished after 23 minutes (17-33 minutes) [median; interquartile range (IQR)] and after 70 minutes (IQR, 56-85) in group II (n = 79). The definitive management plan based on a completed diagnostic workup was devised after 47 minutes (IQR, 37-59) in group I and after 82 minutes (IQR, 66-110) in group II.

CONCLUSION

A whole-body MSCT-based diagnostic approach to multiple injuries might shorten the time interval from arrival in the trauma emergency room until obtaining a final diagnosis and management plan in patients with multiple injuries and might, therefore, contribute to improvements in patient care.

CT of the musculoskeletal system: what is left is the days of MRI?

Magnetic resonance imaging (MRI) plays a central role in the modern imaging of musculoskeletal disorders, due to its ability to produce multiplanar images and characterise soft tissues accurately. However, computed tomography (CT) still has an important role to play, not merely as an alternative to MRI, but as being the preferred imaging investigation in some situations. This article briefly reviews the history of CT technology, the technical factors involved and a number of current applications, as well as looking at future areas where CT may be employed. The advent of ever-increasing numbers of rows of detectors has opened up more possible uses for CT technology. However, diagnostic images may be obtained from CT systems with four rows of detectors or more, and their ability to produce near isotropic voxels and therefore multiplanar reformats.

MDCT in the evaluation of skeletal trauma: principles, protocols, and clinical applications

Multidetector computed tomography (MDCT) scanners have made volume imaging possible and are used extensively to study polytrauma patients, especially in the evaluation of the spine and peripheral skeleton. An MDCT scanner coupled with a modern workstation has become an essential diagnostic tool for any emergency department. Familiarity with the basic physical principles of MDCT such as projection data, section collimation, and beam collimation is important to achieve high-quality imaging while keeping unnecessary radiation to a minimum. After a polytrauma MDCT examination, images can be reconstructed to obtain different slice thickness, slice interval, fields of view, or reconstruction kernels. No additional scanning is needed for imaging the thoracolumbar spine or bony pelvis. High-quality multiplanar reformation (MPR) and three-dimensional (3-D) images can be created at the workstation using the volumetric data. However, MDCT is a high-dose examination, and care should be taken to use as low a dose as possible. In the musculoskeletal system, MDCT has long been used for evaluation of spinal and pelvic trauma; however, the frequency of its use in extremity trauma has been low. In the extremities, radiography seems to underestimate the extent and severity of injury, especially in complex areas such as the shoulder, elbow, wrist, knee, and ankle. MDCT in the extremities is helpful in fracture detection, evaluation, characterization, and treatment planning. The MPR images give excellent structural detail, and the 3-D images help in understanding the spatial relations, which is important for fracture classification and for preoperative planning. MDCT is also helpful in the follow-up of postoperative results, even in the presence of hardware. Tendon injuries can also be evaluated with MDCT.

Imaging of spinal trauma

Approximately 2% to 3% of blunt trauma victims suffer injury to the spinal column each year, often with devastating consequences. This article discusses clinical criteria for screening for spinal injury and the increasing roles of multidetector CT and MR imaging in the evaluation of spinal trauma. Both CT and MR imaging safety issues also are addressed. Lastly, the role of imaging in the evaluation of whiplash injury, instability, vascular injury, and delayed traumatic sequelae is discussed.