Diagnostic Imaging

(1)

Contents I

MEDICAL RADIOLOGY Diagnostic Imaging

Editors:

A. L. Baert, Leuven K. Sartor, Heidelberg

(2)

Contents III

David Wilson (Ed.)

Paediatric

Musculoskeletal Disease

With an Emphasis on Ultrasound

With Contributions by

G. Allan · S. Bianchi · R. Cheung · C. Groves · C. Martinoli · P. J. O’Connor P. Thomà · M. Valle · D. Wilson

Foreword by

A. L. Baert

With 88 Figures in 141 Separate Illustrations, 11 in Color and 3 Tables

123

(3)

IV Contents

David Wilson, FRCP, FRCR Department of Radiology Nufﬁ eld Orthopaedic Centre NHS Trust

Windmill Road, Headington Oxford OX3 7LD

UK

Medical Radiology · Diagnostic Imaging and Radiation Oncology Series Editors: A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Molls · K. Sartor Continuation of Handbuch der medizinischen Radiologie

Encyclopedia of Medical Radiology

Library of Congress Control Number: 2003060242

ISBN 3-540-66828-4 Springer Berlin Heidelberg New York

This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, speciﬁ - cally the rights of translation, reprinting, reuse of illustrations, recitations, broadcasting, reproduction on microﬁ lm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law.

Springer is part of Springer Science+Business Media http//www.springeronline.com

쏘 Springer-Verlag Berlin Heidelberg 2005 Printed in Germany

The use of general descriptive names, trademarks, etc. in this publication does not imply, even in the absence of a speciﬁ c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every case the user must check such information by consulting the relevant literature.

Medical Editor: Dr. Ute Heilmann, Heidelberg Desk Editor: Ursula N. Davis, Heidelberg Production Editor: Kurt Teichmann, Mauer

Cover-Design and Typesetting: Verlagsservice Teichmann, Mauer Printed on acid-free paper – 21/3150xq – 5 4 3 2 1 0

(4)

Contents V

Dedication

To all your children and

to the young people in our family:

Emma, Phil, Iain, Neil,

Rachael, Siân, Natalie and Jack.

(5)

Contents VII

During recent years the important role of ultrasound in the diagnosis and management of musculoskeletal diseases has become well established. The speciﬁ c strengths of this modal- ity become quite evident in the examination of children because of the absence of ionising radiation and the close interaction between examiner and patient.

This volume highlights the role of ultrasound as a primary or adjuvant diagnostic modal- ity in a range of musculoskeletal disorders and describes its contribution for problem solving and for better patient management.

The eminently readable text is completed by superb illustrations.

The editor, D. Wilson, is a world-renowned expert in the ﬁ eld with a great dedication and interest in paediatric ultrasound. The authors of individual chapters were invited to partici- pate because of their long-standing experience and major contributions to the radiological literature on the topic.

I would like to thank the editor and the authors and congratulate them most sincerely for their superb efforts that have resulted in this outstanding volume.

This book will be of great value not only for general and paediatric radiologists but also for paediatricians and paediatric orthopaedic surgeons. It will provide all of these specialists with state-of-the-art information on a narrow but fascinating medical ﬁ eld.

I am conﬁ dent that it will meet the same success with readers as previous volumes in this series.

Leuven Albert L. Baert

Foreword

(6)

Contents IX

Preface

When I started examining patients with ultrasound for musculoskeletal disorders we were still using static “B” scanners. CT was a new invention and MRI did not exist. Whilst my contemporaries were enthusiastically specialising in the use of nuclear medicine and ultrasound, I chose to take an interest and eventually a full-time specialisation in a system rather than a machine. The principal strength of this choice is that I use all imaging methods and hopefully have insight into their advantages and weaknesses in each potential application. It does mean that I have little knowledge of what goes on in the abdomen, chest or brain and that, for better or worse, I will have to work with orthopaedic surgeons and rheumatologists for the remainder of my career.

Reading textbooks on imaging I am struck by the sometimes tortuous reasoning that others employ to explain why their preferred technique is useful to make a diagnosis in all illnesses. They are at times blinkered to the strengths of a rival method and often overlook the potential for correlation of the signs on more than one technique. My view is that musculoskeletal radiologists should be skilled in the interpretation of plain ﬁ lms, ultrasound, nuclear medicine, CT and MRI. To miss out one of these is to be like a gardener with a fork and rake but no spade. There is no place for rivalry as all are needed to carry out an accurate, safe and effective practice.

I was asked to edit a text on paediatric musculoskeletal imaging. I have chosen to empha- sise the role of ultrasound, which is very well suited to the examination of children, who commonly will not lie still, require reassurance by personal contact and need a non-invasive and comfortable method of examination. We are all aware of the dangers of ionising radiation and the potential for fear and anxiety when inside the bore of an MR system. However, CT and MRI are powerful means of making a diagnosis, and sedation or anaesthesia are practical options.

Clinicians, therapists and diagnosticians need to understand the strengths and weaknesses of each imaging method with knowledge of the alternative methods.

This book describes a range of practical problems in diagnosis and therapy where ultrasound has a signifi cant role to play. In some circumstances ultrasound is the most effective means of diagnosis, as in the assessment of developmental dysplasia or stress-testing the integrity of a tendon. We consider the support ultrasound lends to other methods, perhaps confi rming a diagnosis, for example the detection of infl ammatory synovitis in juvenile arthropathy. Lastly, we discuss where ultrasound is a weaker alternative to other more com- prehensive methods, such as in the detection of periosteal reaction over an area of osteomyelitis.

We do not cover those areas of musculoskeletal practice where ultrasound has no current role. For example, CT and MRI are the most effective means of making a diagnosis of hind- foot coalition, but ultrasound cannot show us the deep structures.

(7)

X Contents

Ultrasound machines vary widely in their ability to realise images of superﬁ cial lesions.

In musculoskeletal applications most lesions are near the surface and care must be taken to select the best equipment . Even the latest machines may fail in this area, and thorough knowledge of the technology is important to guide our patients to effective diagnosis and treatment.

Ultrasound, CT and MRI demand a wide knowledge of anatomy, including variations of normal. Ultrasound is a dynamic examination, and the examiner must also understand the biomechanics and function of the regions studied.

The authors of the chapters in this book are all renowned musculoskeletal imaging specialists. They have been briefed to discuss all the imaging appropriate to a suspected diagnosis, and we hope that the reader will gain an understanding of where each method ﬁ ts into a modern practice.

Oxford David Wilson

(8)

Contents XI

1 Congenital and Developmental Disorders

David Wilson and Ruth Cheung . . . 1

1.1 Introduction. . . 1

1.2 Developmental Dysplasia of the Hip . . . 1

1.2.1 Clinical Background . . . 1

1.2.2 Role of Imaging in Detection . . . 2

1.2.3 Role of Imaging in Treatment . . . 4

1.2.4 Potential Developments . . . 5

1.3 Focal Defects . . . 7

1.3.2 Role of Imaging . . . 8

1.4 Talipes Equinovarus . . . 9

1.5 Neural Tube Defects . . . 10

References and Further Reading. . . 16

2 Trauma and Sports-related Injuries Philip J. O‘Connor and Clare Groves . . . 19

2.1 General Principles. . . 19

2.1.1 Biomechanics. . . 19

2.1.2 Imaging. . . 20

2.2 Acute Trauma. . . 20

2.2.1 Acute Fracture Patterns . . . 20

2.2.2 Foreign Bodies. . . 24

2.2.3 Haematoma . . . 25

2.2.4 Muscles and Tendons . . . 26

2.3 Chronic Trauma. . . 28

2.3.1 Chronic Fracture Patterns . . . 28

2.4 The Osteochondroses . . . 32

2.4.1 Osteochondritis Dissecans. . . 32

2.4.2 Panner’s Disease . . . 33

2.4.3 Medial Epicondylitis (Little League Elbow). . . 34

Contents

(9)

XII Contents

2.5 Accessory Ossicles. . . 34

2.6 Bursae . . . 34

2.7 Summary . . . 37

3 Ultrasonography of Tendons and Ligaments Maura Valle, Stefano Bianchi, Paolo Tomà, and Carlos Martinoli . . . 39

3.2 Normal Anatomy. . . 39

3.2.1 Tendons . . . 39

3.2.2 Ligaments . . . 40

3.3 Examination Techniques and Normal Imaging Findings . . . 40

3.3.1 US . . . 40

3.3.2 MR imaging . . . 42

3.4 Tendon Abnormalities . . . 43

3.4.1 Overuse Injuries . . . 43

3.4.2 Avulsion Injuries . . . 43

3.4.3 Snapping Hip . . . 46

3.4.4 Degenerative and Inﬂ ammatory Conditions . . . 47

3.5 Ligament Abnormalities. . . 50

3.6 Conclusion . . . 51

4 Inﬂ ammatory Disorders David Wilson. . . 53

4.2 Irritable Hip . . . 53

4.2.4 Management Protocol . . . 57

4.3 Synovitis . . . 58

4.4 Osteomyelitis and Soft-tissue Infection. . . 59

(10)

Contents XIII

5 Soft Tissue Tumours in Children

Gina Allen. . . 67

5.2 US . . . 67

5.2.1 Plain Radiographs. . . 69

5.2.2 Magnetic Resonance Imaging . . . 69

5.3 Computed Tomography . . . 70

5.4 Nuclear Medicine . . . 70

5.5 Disease characteristics . . . 71

5.5.1 Benign Lesions Seen On US. . . 71

5.5.2 Vascular Anomalies. . . 76

5.6 Potential Developments . . . 82

6 Interventional Techniques David Wilson. . . 85

6.2 Biopsy . . . 85

6.2.1 Soft Tissue Masses. . . 85

6.2.2 Bone Masses. . . 87

6.3 Aspiration. . . 88

6.4 Local Anaesthetic Blocks . . . 89

6.5 Osteoid Osteoma Ablation . . . 89

Subject Index . . . 93

List of Contributors. . . 98