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Fatigue fractures of the proximal tibia simulating malignancy
682
CLINICAL RADIOLOGY
and biopsy all of whom had abnormal clinical findings on digital examination, suspicious, but not diagnostic of malignancy. Biopsy was performed on predominantlY echo-poor lesions in 43 patients and echogenic lesions in two. Lesions measured 0.7-2 cm in diameter. Prostate cancer was found in 15 patients (33%) all of whom had predominantly echo-poor lesions, confined to the peripheral zone of the gland in nine and extending into the central zone of the gland in six. Biopsy of 28 echo-poor lesions revealed benign prostatic hypertrophy in four and prostatitis in three. The two echogenic lesions biopsied were also benign. This report supports the currently held concept that small prostatic tumours are echo-poor on TRUS, but that both histologically benign hypertrophy and prostatitis have similar ultrasound appearances. In patients in whom there is clinical suspicion of prostatic abnormality on digital examination and in whom echo-poor lesions are identified prostatic biopsy is indicated.
RADIOLOGY BEFORE PARATHYROID SURGERY M. N. H. LLOYD, W. R. LEES and E. MILROY
Middlesex Hospital, London Two hundred and seven cases having parathyroid exploration over 4 years were studied. Skeletal complications of hyperparathyroidism were demonstrated in 14% (24 of 176) and urological complications in 42% (72 of 172). Evidence of past or present gallstones was seen in 30% (32 of 106). Of 173 patients without previous parathyroid exploration, adenomas were found in 152, hyperplasia in 19 and two had negative explorations. Pre-operative localisation in these was usually performed with parathyroid venous sampling (PVS) and ultrasound. PVS had a sensitivity of 67% (78 of 117), localised precisely in 44% (51 of 117) with false positive rate of 14% (16 of 117). Ultrasound had a sensitivity Of 32% (51 of 158), localised precisely in 20% (33 of 158) with 8% false positives. Relatively poor results from ultrasound were related to operator inexperience, small glands, thyroid abnormality, previous neck surgery and multigland disease. The most experienced ultrasonologist achieved a sensitivity of 65% (28 of 43) with precise localisation in 60% and a false positive rate of 16%. Combined, the two techniques had an overall sensitivity of 61% but with 16% false positive results. Parathyroid venous sampling is very expensive and carries a small morbidity but is relatively simple to perform. Ultrasound is cheap and rapid to perform with no morbidity but requires good equipment and an experienced operator. ASSESSMENT OF RECTAL TUMOURS BY ENDOLUMINAL ULTRASOUND M. J. BULL, W. P. MORGAN and R. W. BURY
Royal Hallamshire Hospital, Sheffield The close apposition of a high frequency (7 MHz) ultrasound probe against the rectal wall allows for a high resolution image in which distinct layers can be seen corresponding to known histological structures. In particular, the good visualisation of the serosa is a good guide to any spread of tumour beyond the rectal wall. A study is described of over 30 cases of rectal tumours which were assessed by endoluminal ultrasound (ELU), computed tomography, biochemical markers and clinical evaluation. These are correlated with the operative findings and final histology. Endoluminal ultrasound is shown to be an easy, safe, well tolerated procedure which allows more accurate local staging of both benign and malignant rectal tumours to be made.
in association with flexion-distraction injury. In 17 patients the level of injury was between T12 and L3. The highest level involved was T6 and the lowest L5. In patients who had both CT and tomography, CT was more difficult to interpret and yielded additional information in a minority of patients (apart from avulsion injuries of the transverse and spinous processes). Minor degrees of rotation were noted to affect the visibility of abnormalities on sagittal reformatting. CT most often missed fractures in the axial plane which is the orientation favoured by this mechanism of injury. We prefer conventional tomography for the evaluation of these patients, recommending CT for investigation of the patient with a neurological deficit and for assessment of suspected compromise of the bony spinal canal.
FATIGUE FRACTURES OF THE PROXIMAL TIBIA SIMULATING MALIGNANCY A. M. DAVIES, N. EVANS and R. J. GRIMER
Royal Orthopaedic Hospital, Birmingham Although the proximal tibia is a classic site for the fatigue type of stress fracture they are commonly mistaken for a malignant sarcoma of bone. We present the clinical and radiological features of nine cases seen in a 2V2 year period. Seven of the cases referred to the Bone Tumour Service with the diagnosis of a probable sarcoma. All 9 patients were male but only two gave a history of a recent increase in physical activity. The plain radiographic findings consisted of an uninterrupted lamellar periosteal reaction arising posteromedially in the proximal tibia with the fracture visible through the thickened posterior cortex. Bone scan revealed a fusiform focus of increased uptake in the posteromedial cortex of the tibia with varying degrees of activity in the adjacent metaphysis. CT on a soft tissue window showed perifracture oedoma in the absence of a soft tissue mass. The attenuation of the underlying medulla was increased due to fibrosis and hyperaemia. On an extended window setting both periosteal and endosteal callus was identified, maximal in the posteromedial tibia and the fractures were best demonstrated on a cortical window. Clinical and radiological features that differentiate a fatigue fracture from a sarcoma are discussed. THE ANATOMY OF THE SHOULDER JOINT ON CT ARTHROGRAPHY AND THE ROLE OF THE TECHNIQUE IN RECURRENT DISLOCATION J. V. COOK and R. T A Y A R
St Helier Hospital, London Fifty-one patients (37 men and 17 women) with a history of documented recurrent dislocation (41) or suspected instability of the shoulder joint (10) were examined by CT arthrography. Those with recurrent dislocation showed most abnormalities, plain double contrast arthrography was abnormal in seven and abnormalities were noted on CT in 36. These patients often have multiple abnormalities and unless extensive exploration is undertaken at the time of surgery, some lesions may be overlooked and lead to continuing morbidity. We consider that pre-operative CT arthrography is useful in identifying the site and extent of capsular and labral abnormalities, thus aiding in the selection of the appropriate surgical procedure and avoiding the necessity for lengthy surgery. This paper: 1 Describes the technique involved. 2 Demonstrates the normal appearances and some anatomical variants which may lead to misinterpretation. 3 Identifies the main abnormalities seen in recurrent dislocation.
IMAGING OF FLEXION-DISTRACTION INJURIES OF THE THORACOLUMBAR SPINE R. G. W. LAMBERT, E. J. BECKER and J. D. RUBENSTEIN
CT SCANNING OF DISTAL TIBIAL EPIPHYSEAL FRACTURES IN ADOLESCENTS K. UDJUS and P. McDONALD
Toronto General Hospital and Sunnybrook Medical Centre, Toronto, Canada
Children's Hospital of Eastern Ontario, Ontario, Canada
We reviewed 21 cases of flexion-distraction injury of the thoracolumbar spine. Eighteen patients had computed tomography (CT), 14 had conventional tomography and 11 had both. In our experience, these injuries are of greater diversity than previously emphasised. In five patients the radiographic findings were asymmetrical making analysis of the injury more difficult. Four patients had a sagittal fracture of the vertebral body, usually considered pathognomonic of a 'burst' injury and not previously reported
Since our GE 8800 CT scanner was installed in 1980, 90 patients have undergone CT examination of the ankle for distal epiphyseal fracture of the tibia. Eighty-eight of those were between the ages of 10 and 17-years-old, and were included in the study. Sixty-two of the fractures were of triplane type, over two-thirds of the total. There were 13 juvenile Tillaux fractures, as well as nine of Salter-Harris type II, two of Salter-Harris type Ill and two of SalterHarris type IV. The age distribution showed a peak for girls at age 13 and for boys at
CLINICAL RADIOLOGY
and biopsy all of whom had abnormal clinical findings on digital examination, suspicious, but not diagnostic of malignancy. Biopsy was performed on predominantlY echo-poor lesions in 43 patients and echogenic lesions in two. Lesions measured 0.7-2 cm in diameter. Prostate cancer was found in 15 patients (33%) all of whom had predominantly echo-poor lesions, confined to the peripheral zone of the gland in nine and extending into the central zone of the gland in six. Biopsy of 28 echo-poor lesions revealed benign prostatic hypertrophy in four and prostatitis in three. The two echogenic lesions biopsied were also benign. This report supports the currently held concept that small prostatic tumours are echo-poor on TRUS, but that both histologically benign hypertrophy and prostatitis have similar ultrasound appearances. In patients in whom there is clinical suspicion of prostatic abnormality on digital examination and in whom echo-poor lesions are identified prostatic biopsy is indicated.
RADIOLOGY BEFORE PARATHYROID SURGERY M. N. H. LLOYD, W. R. LEES and E. MILROY
Middlesex Hospital, London Two hundred and seven cases having parathyroid exploration over 4 years were studied. Skeletal complications of hyperparathyroidism were demonstrated in 14% (24 of 176) and urological complications in 42% (72 of 172). Evidence of past or present gallstones was seen in 30% (32 of 106). Of 173 patients without previous parathyroid exploration, adenomas were found in 152, hyperplasia in 19 and two had negative explorations. Pre-operative localisation in these was usually performed with parathyroid venous sampling (PVS) and ultrasound. PVS had a sensitivity of 67% (78 of 117), localised precisely in 44% (51 of 117) with false positive rate of 14% (16 of 117). Ultrasound had a sensitivity Of 32% (51 of 158), localised precisely in 20% (33 of 158) with 8% false positives. Relatively poor results from ultrasound were related to operator inexperience, small glands, thyroid abnormality, previous neck surgery and multigland disease. The most experienced ultrasonologist achieved a sensitivity of 65% (28 of 43) with precise localisation in 60% and a false positive rate of 16%. Combined, the two techniques had an overall sensitivity of 61% but with 16% false positive results. Parathyroid venous sampling is very expensive and carries a small morbidity but is relatively simple to perform. Ultrasound is cheap and rapid to perform with no morbidity but requires good equipment and an experienced operator. ASSESSMENT OF RECTAL TUMOURS BY ENDOLUMINAL ULTRASOUND M. J. BULL, W. P. MORGAN and R. W. BURY
Royal Hallamshire Hospital, Sheffield The close apposition of a high frequency (7 MHz) ultrasound probe against the rectal wall allows for a high resolution image in which distinct layers can be seen corresponding to known histological structures. In particular, the good visualisation of the serosa is a good guide to any spread of tumour beyond the rectal wall. A study is described of over 30 cases of rectal tumours which were assessed by endoluminal ultrasound (ELU), computed tomography, biochemical markers and clinical evaluation. These are correlated with the operative findings and final histology. Endoluminal ultrasound is shown to be an easy, safe, well tolerated procedure which allows more accurate local staging of both benign and malignant rectal tumours to be made.
in association with flexion-distraction injury. In 17 patients the level of injury was between T12 and L3. The highest level involved was T6 and the lowest L5. In patients who had both CT and tomography, CT was more difficult to interpret and yielded additional information in a minority of patients (apart from avulsion injuries of the transverse and spinous processes). Minor degrees of rotation were noted to affect the visibility of abnormalities on sagittal reformatting. CT most often missed fractures in the axial plane which is the orientation favoured by this mechanism of injury. We prefer conventional tomography for the evaluation of these patients, recommending CT for investigation of the patient with a neurological deficit and for assessment of suspected compromise of the bony spinal canal.
FATIGUE FRACTURES OF THE PROXIMAL TIBIA SIMULATING MALIGNANCY A. M. DAVIES, N. EVANS and R. J. GRIMER
Royal Orthopaedic Hospital, Birmingham Although the proximal tibia is a classic site for the fatigue type of stress fracture they are commonly mistaken for a malignant sarcoma of bone. We present the clinical and radiological features of nine cases seen in a 2V2 year period. Seven of the cases referred to the Bone Tumour Service with the diagnosis of a probable sarcoma. All 9 patients were male but only two gave a history of a recent increase in physical activity. The plain radiographic findings consisted of an uninterrupted lamellar periosteal reaction arising posteromedially in the proximal tibia with the fracture visible through the thickened posterior cortex. Bone scan revealed a fusiform focus of increased uptake in the posteromedial cortex of the tibia with varying degrees of activity in the adjacent metaphysis. CT on a soft tissue window showed perifracture oedoma in the absence of a soft tissue mass. The attenuation of the underlying medulla was increased due to fibrosis and hyperaemia. On an extended window setting both periosteal and endosteal callus was identified, maximal in the posteromedial tibia and the fractures were best demonstrated on a cortical window. Clinical and radiological features that differentiate a fatigue fracture from a sarcoma are discussed. THE ANATOMY OF THE SHOULDER JOINT ON CT ARTHROGRAPHY AND THE ROLE OF THE TECHNIQUE IN RECURRENT DISLOCATION J. V. COOK and R. T A Y A R
St Helier Hospital, London Fifty-one patients (37 men and 17 women) with a history of documented recurrent dislocation (41) or suspected instability of the shoulder joint (10) were examined by CT arthrography. Those with recurrent dislocation showed most abnormalities, plain double contrast arthrography was abnormal in seven and abnormalities were noted on CT in 36. These patients often have multiple abnormalities and unless extensive exploration is undertaken at the time of surgery, some lesions may be overlooked and lead to continuing morbidity. We consider that pre-operative CT arthrography is useful in identifying the site and extent of capsular and labral abnormalities, thus aiding in the selection of the appropriate surgical procedure and avoiding the necessity for lengthy surgery. This paper: 1 Describes the technique involved. 2 Demonstrates the normal appearances and some anatomical variants which may lead to misinterpretation. 3 Identifies the main abnormalities seen in recurrent dislocation.
IMAGING OF FLEXION-DISTRACTION INJURIES OF THE THORACOLUMBAR SPINE R. G. W. LAMBERT, E. J. BECKER and J. D. RUBENSTEIN
CT SCANNING OF DISTAL TIBIAL EPIPHYSEAL FRACTURES IN ADOLESCENTS K. UDJUS and P. McDONALD
Toronto General Hospital and Sunnybrook Medical Centre, Toronto, Canada
Children's Hospital of Eastern Ontario, Ontario, Canada
We reviewed 21 cases of flexion-distraction injury of the thoracolumbar spine. Eighteen patients had computed tomography (CT), 14 had conventional tomography and 11 had both. In our experience, these injuries are of greater diversity than previously emphasised. In five patients the radiographic findings were asymmetrical making analysis of the injury more difficult. Four patients had a sagittal fracture of the vertebral body, usually considered pathognomonic of a 'burst' injury and not previously reported
Since our GE 8800 CT scanner was installed in 1980, 90 patients have undergone CT examination of the ankle for distal epiphyseal fracture of the tibia. Eighty-eight of those were between the ages of 10 and 17-years-old, and were included in the study. Sixty-two of the fractures were of triplane type, over two-thirds of the total. There were 13 juvenile Tillaux fractures, as well as nine of Salter-Harris type II, two of Salter-Harris type Ill and two of SalterHarris type IV. The age distribution showed a peak for girls at age 13 and for boys at