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An audit of the post-micturition film: Is it really necessary?
ABSTRACTS
tary techniques so as to maximize serious pathology in the colonoscopy group (enabling biopsy and polypectomy) and minimizing the number of patients undergoing both investigations. The aim of this study was to rationalize colonic investigation based on patient clinical features and the clinicians index of suspicion (CIS). Colonic investigation requests in new hospital patients were allotted to BE or colonoscopy by a panel of a Radiologist and Gastroenterologist on the basis of information supplied on a special request form. These included symptoms such as change of bowel habit, rectal bleeding, weight loss, abdominal pain and rigid sigmoidoscopic findings. The CIS of finding significant pathology was also recorded (high, moderate or low). A total of 401 patients were entered into the study: 252 had BE and 149 had colonoscopy. Eighty-one had significant pathology (35 carcinoma, 17 polyps > 1 cm, 24 colitis). Diagnostic rate for polyps was greater in colonoscopy than BE (13/17 vs 4/17). In carcinoma it was higher for BE than colonoscopy (23/35 vs 12/35). The CIS was higher in patients with significant pathology ( > 50%) compared with normal. The number of patients requiring second investigation was 21. Our study shows that it is possible to predict patients with significant pathology based on symptom analysis and clinicians index of suspicion. Colonic investigation was rationalized and duplication of procedures minimized.
A U D I T O F 3D C O M P U T E D T O M O G R A P H Y IN O R T H O P A E D I C PATIENTS G. T. R O T T E N B E R G and W. R. LEES
Deparmwnt of Diagnostic hnaging, The Middlesex Hospital, London 3D CT has been available for several years but its clinical use remains unclear in the investigation of orthopaedic patients. This study was established to evaluate the clinical use of 3D CT. The 3D CT scans of the last 50 orthopaedic patients were reviewed. Scans were compared to the 2D CT. The effect of the scans on clinical management was assessed. Thirty per cent of patients were examined for trauma. Most benefit was obtained in patients with major trauma of the pelvis, knee and ankle. The presence of significant bony displacement was associated with increased use in operative planning. Twenty per cent of patients were examined for custom-made prostheses prior to hip replacements. Life-size solid models constructed together with a cad cam data set proved invaluable in planning and performing surgery. Twenty per cent were scanned for a variety of bone tumours. The 3D reconstruction was of limited value compared to information gained from MRI. 3D reconstruction appeared most useful in providing increased perceptual understanding of complex fractures and in the manufacture of custom-made prostheses. The arrival of fast CT scanners will enable rapid acquisition of data even in the acutely traumatized patient which will lead to an increase in the demand and utility of 3D images.
363
P S E U D O - T U M O U R OF T H E S H O U L D E R - THE L A R G E S U B A C R O M I A L B U R S A D E M O N S T R A T E D BY MRI K. J. FAIRBA1RN, H. C. BURRELL, W. A. WALLACE and B. J. PRESTON
Department of Radiology and Orthopaedic Accident Surgery, UniversiO' Hospital, Queen :3 Medical Centre, Nottingham The subacromial bursa (SAB) lies between the rotator cuff and the acromion and extends under the deltoid. A small amount of fluid is often demonstrated on MRI within the bursa associated with impingement syndrome. A large collection of fluid is unusual and may give a false clinical impression of a a tumour. We present three cases of an enlarged SAB where the clinical impression was of a tumour. Case 1. This case demonstrated the full extent of the bursa on MRI. No rotator cuff abnormality was demonstrated. A diagnosis of Stage I of the impingement syndrome was made. Case 2. Anterior shoulder dislocation complicated by a mass clinically and on AP X-ray. This case illustrates an unusual plain film appearance. Case 3. The M RI demonstrated a large SAB with synovial thickening. There was also a large gleno-humeral effusion, rupture of long head of biceps and a 'button hole' appearance of supraspinatus. The latter is likely to represent a previous tear of supraspinatus. Conclusion: The diagnosis of a large SAB should be considered when performing MRI of the shoulder for a suspected tumour. If demonstrated, we would recommend an MRI protocol for full assessment of the inpingement syndrome.
DETECTION OF O C C U L T W R I S T I N J U R I E S BY MAGNETIC RESONANCE I M A G I N G W. C. G. PEH, L. A. G I L U L A and A. J. WILSON*
Department of Diagnostic Radiology, University of Hong Kong, Hong Kong and the *Mallinckrodt Institute of Radiology, Washington Universio, Medical Centre, St Louis, MO, USA Detection of occult osseous injuries by magnetic resonance imaging (MRI) has been recognized in the knee, humerus, pelvis and vertebra, but has not been emphasized in the wrist. Six patients with such injuries in the wrist were reviewed retrospectively. MRI demonstrated a fracture line affecting the distal radius, scaphoid, capitate and hamate in five patients, and bone bruising of the lunate in one patient. In one case, CT failed to demonstrate the fracture. In another case, the fracture was obscured on initial MR scans by intense bone marrow oedema but was clearly defined on repeat MRI. The fracture was seen as a band of low signal intensity on both T1- and T2-weighted images, while surrounding oedema and bone bruising produced diffuse low signal intensity on Tl-weighted and high signal intensity on T2-weighted images. In all but one patient who was lost to follow-up, clinical management was based on diagnosis of bony injury by MRI. Without MRI information, the diagnosis in these patients would have been difficult or impossible. These five patients were immobilized in plaster casts, with subsequent recovery. MRI is useful in the detection, management and follow-up of occult osseous wrist injuries.
A N A U D I T O F THE P O S T - M I C T U R I T I O N FILM: IS IT REALLY NECESSARY? J. A. S. BROOKES, U. PATEL and D. R I C K A R D S
Department of Uroradiology, The Middh, sex Hospital, St Peters Group, London
S A C R A L I N S U F F I C I E N C Y FRACTURES: AN U N D E R - D I A G N O S E D P R O B L E M IN T H E E L D E R L Y L. C. MORUS, S. J. MORRIS, P. FACEY and J. I. S. REES
With growing awareness of radiation risks and the costs of noninformative investigation, we examined the value of the post-contrast post micturition film (PCPM) as part of the standard IVU. In 100 prospective cases, the PCPM films were reviewed to assess what further information was revealed with particular attention to bladder residual volume and upper tract damage. Bladder dimensions on both pre- and post-contrast post micturition films were compared. All bladder volume measurements were carried out blind. Finally any unexpected pathology revealed on the PCPM film was noted. The pre- and post-contrast bladder dimensions demonstrated good linear correlation (r>0.9). In no case did the PCPM film add further unexpected information, but in 10% of cases a full length PCPM film was helpful in making a conclusive diagnosis; e.g. confirmation of level of low ureteric obstruction. In conclusion, the PCPM film should only be conducted where specifically indicated and as a full length radiograph. There is no place for the coned bladder PCPM film or PCPM film for bladder residual volume alone.
With an ever-increasing elderly population the incidence of osteoporosis is rising with considerable financial implications for the health services. Sacral insufficiency fractures are common in osteoporosis and are difficult to diagnose on plain radiographs. Failure to diagnose these fractures may lead to unnecessary investigation and prolonged hospitalization with its attendant risks. Other centres have reported a characteristic pattern of tracer uptake using bone scintigraphy in sacral insufficiency fractures; the Honda sign. We report our experience where a variant of this pattern of showing uptake limited to the sacral alae, simulating sacroilitis was observed. Over a 6 month period, six elderly women with known osteoporosis and previous osteoporotic fractures, five of whom were on steroids, presented for radionuclide bone scanning with long-standing symptoms of low back pain. Sacral fractures were not seen on plain radiography. In all patients, increased radionuclide uptake was confined to the sacral alae only. Fractures were subsequently confirmed in all patients with CT scanning.
Department of Radiology, UniversiO, Hospital of Wales, Cardiff"
tary techniques so as to maximize serious pathology in the colonoscopy group (enabling biopsy and polypectomy) and minimizing the number of patients undergoing both investigations. The aim of this study was to rationalize colonic investigation based on patient clinical features and the clinicians index of suspicion (CIS). Colonic investigation requests in new hospital patients were allotted to BE or colonoscopy by a panel of a Radiologist and Gastroenterologist on the basis of information supplied on a special request form. These included symptoms such as change of bowel habit, rectal bleeding, weight loss, abdominal pain and rigid sigmoidoscopic findings. The CIS of finding significant pathology was also recorded (high, moderate or low). A total of 401 patients were entered into the study: 252 had BE and 149 had colonoscopy. Eighty-one had significant pathology (35 carcinoma, 17 polyps > 1 cm, 24 colitis). Diagnostic rate for polyps was greater in colonoscopy than BE (13/17 vs 4/17). In carcinoma it was higher for BE than colonoscopy (23/35 vs 12/35). The CIS was higher in patients with significant pathology ( > 50%) compared with normal. The number of patients requiring second investigation was 21. Our study shows that it is possible to predict patients with significant pathology based on symptom analysis and clinicians index of suspicion. Colonic investigation was rationalized and duplication of procedures minimized.
A U D I T O F 3D C O M P U T E D T O M O G R A P H Y IN O R T H O P A E D I C PATIENTS G. T. R O T T E N B E R G and W. R. LEES
Deparmwnt of Diagnostic hnaging, The Middlesex Hospital, London 3D CT has been available for several years but its clinical use remains unclear in the investigation of orthopaedic patients. This study was established to evaluate the clinical use of 3D CT. The 3D CT scans of the last 50 orthopaedic patients were reviewed. Scans were compared to the 2D CT. The effect of the scans on clinical management was assessed. Thirty per cent of patients were examined for trauma. Most benefit was obtained in patients with major trauma of the pelvis, knee and ankle. The presence of significant bony displacement was associated with increased use in operative planning. Twenty per cent of patients were examined for custom-made prostheses prior to hip replacements. Life-size solid models constructed together with a cad cam data set proved invaluable in planning and performing surgery. Twenty per cent were scanned for a variety of bone tumours. The 3D reconstruction was of limited value compared to information gained from MRI. 3D reconstruction appeared most useful in providing increased perceptual understanding of complex fractures and in the manufacture of custom-made prostheses. The arrival of fast CT scanners will enable rapid acquisition of data even in the acutely traumatized patient which will lead to an increase in the demand and utility of 3D images.
363
P S E U D O - T U M O U R OF T H E S H O U L D E R - THE L A R G E S U B A C R O M I A L B U R S A D E M O N S T R A T E D BY MRI K. J. FAIRBA1RN, H. C. BURRELL, W. A. WALLACE and B. J. PRESTON
Department of Radiology and Orthopaedic Accident Surgery, UniversiO' Hospital, Queen :3 Medical Centre, Nottingham The subacromial bursa (SAB) lies between the rotator cuff and the acromion and extends under the deltoid. A small amount of fluid is often demonstrated on MRI within the bursa associated with impingement syndrome. A large collection of fluid is unusual and may give a false clinical impression of a a tumour. We present three cases of an enlarged SAB where the clinical impression was of a tumour. Case 1. This case demonstrated the full extent of the bursa on MRI. No rotator cuff abnormality was demonstrated. A diagnosis of Stage I of the impingement syndrome was made. Case 2. Anterior shoulder dislocation complicated by a mass clinically and on AP X-ray. This case illustrates an unusual plain film appearance. Case 3. The M RI demonstrated a large SAB with synovial thickening. There was also a large gleno-humeral effusion, rupture of long head of biceps and a 'button hole' appearance of supraspinatus. The latter is likely to represent a previous tear of supraspinatus. Conclusion: The diagnosis of a large SAB should be considered when performing MRI of the shoulder for a suspected tumour. If demonstrated, we would recommend an MRI protocol for full assessment of the inpingement syndrome.
DETECTION OF O C C U L T W R I S T I N J U R I E S BY MAGNETIC RESONANCE I M A G I N G W. C. G. PEH, L. A. G I L U L A and A. J. WILSON*
Department of Diagnostic Radiology, University of Hong Kong, Hong Kong and the *Mallinckrodt Institute of Radiology, Washington Universio, Medical Centre, St Louis, MO, USA Detection of occult osseous injuries by magnetic resonance imaging (MRI) has been recognized in the knee, humerus, pelvis and vertebra, but has not been emphasized in the wrist. Six patients with such injuries in the wrist were reviewed retrospectively. MRI demonstrated a fracture line affecting the distal radius, scaphoid, capitate and hamate in five patients, and bone bruising of the lunate in one patient. In one case, CT failed to demonstrate the fracture. In another case, the fracture was obscured on initial MR scans by intense bone marrow oedema but was clearly defined on repeat MRI. The fracture was seen as a band of low signal intensity on both T1- and T2-weighted images, while surrounding oedema and bone bruising produced diffuse low signal intensity on Tl-weighted and high signal intensity on T2-weighted images. In all but one patient who was lost to follow-up, clinical management was based on diagnosis of bony injury by MRI. Without MRI information, the diagnosis in these patients would have been difficult or impossible. These five patients were immobilized in plaster casts, with subsequent recovery. MRI is useful in the detection, management and follow-up of occult osseous wrist injuries.
A N A U D I T O F THE P O S T - M I C T U R I T I O N FILM: IS IT REALLY NECESSARY? J. A. S. BROOKES, U. PATEL and D. R I C K A R D S
Department of Uroradiology, The Middh, sex Hospital, St Peters Group, London
S A C R A L I N S U F F I C I E N C Y FRACTURES: AN U N D E R - D I A G N O S E D P R O B L E M IN T H E E L D E R L Y L. C. MORUS, S. J. MORRIS, P. FACEY and J. I. S. REES
With growing awareness of radiation risks and the costs of noninformative investigation, we examined the value of the post-contrast post micturition film (PCPM) as part of the standard IVU. In 100 prospective cases, the PCPM films were reviewed to assess what further information was revealed with particular attention to bladder residual volume and upper tract damage. Bladder dimensions on both pre- and post-contrast post micturition films were compared. All bladder volume measurements were carried out blind. Finally any unexpected pathology revealed on the PCPM film was noted. The pre- and post-contrast bladder dimensions demonstrated good linear correlation (r>0.9). In no case did the PCPM film add further unexpected information, but in 10% of cases a full length PCPM film was helpful in making a conclusive diagnosis; e.g. confirmation of level of low ureteric obstruction. In conclusion, the PCPM film should only be conducted where specifically indicated and as a full length radiograph. There is no place for the coned bladder PCPM film or PCPM film for bladder residual volume alone.
With an ever-increasing elderly population the incidence of osteoporosis is rising with considerable financial implications for the health services. Sacral insufficiency fractures are common in osteoporosis and are difficult to diagnose on plain radiographs. Failure to diagnose these fractures may lead to unnecessary investigation and prolonged hospitalization with its attendant risks. Other centres have reported a characteristic pattern of tracer uptake using bone scintigraphy in sacral insufficiency fractures; the Honda sign. We report our experience where a variant of this pattern of showing uptake limited to the sacral alae, simulating sacroilitis was observed. Over a 6 month period, six elderly women with known osteoporosis and previous osteoporotic fractures, five of whom were on steroids, presented for radionuclide bone scanning with long-standing symptoms of low back pain. Sacral fractures were not seen on plain radiography. In all patients, increased radionuclide uptake was confined to the sacral alae only. Fractures were subsequently confirmed in all patients with CT scanning.
Department of Radiology, UniversiO, Hospital of Wales, Cardiff"