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A case of calcific tendinitis of the gluteus maximus tendon with cortical erosion is presented. Roentgenography demonstrated calcification on the posterior surface of the proximal femur. Computed tomography showed flame-like appearance of calcific tendinitis and bone erosion. Magnetic resonance imaging showed minimal inflammatory reaction around the lesion.
A patient in the second trimester of pregnancy sustained a gunshot wound of the upper cervical spine with a partial Brown-Séquard syndrome. The patient's condition was evaluated by conventional roentgenography, computed axial tomography (CT), and magnetic resonance imaging (MRI). The MRI alone clearly demonstrated the relationship of the bullet and the spinal cord, whereas the CT image was obliterated by metal artifacts. The bullet was removed from the spinal canal by a posterior approach with the patient in the sitting position and in skeletal cervical traction. The neurological status of the patient improved markedly after the surgery.
OBJECTIVES: To develop an intraoperative technique to predict the development of avascular necrosis after internal fixation of femoral neck fractures. DESIGN: Prospective study. SETTING: All patients were treated at the same hospital. PATIENTS/PARTICIPANTS: Sixty-four patients who presented for internal fixation of a femoral neck fracture were enrolled in the study. INTERVENTION: A 2.0-millimeter drill was used to assess the presence and character of bleeding from the femoral head at open reduction and internal fixation of a femoral neck fracture. MAIN OUTCOME MEASUREMENTS: Patients were evaluated postoperatively by history, examination, and roentgenography for the development of avascular necrosis of the femoral head fragment. A minimum two-year follow-up with radiography was required for entry into the study, with an average follow-up of 3.2 years. RESULTS: None of the fifty-six patients with bleeding from the drill holes in the femoral head fragment developed avascular necrosis. Eight of eight patients with no bleeding after reduction developed avascular necrosis. There were no infections or nonunions. CONCLUSIONS: Intraoperative drilling of the femoral head is a highly sensitive and specific predictor for the development of avascular necrosis after femoral neck fractures.
Computerized tomography (CT) can be a useful adjunct to conventional radiography in assessment of acetabular fractures and fracture-dislocations of the hip. Owing to the complex bony architecture of the acetabulum, CT affords better definition of fracture patterns in this region than roentgenography, including special views and tomography. The cross-sectional views of CT offer improved definition of the characteristics of a complex acetabular fracture, including integrity of the weight-bearing dome, congruity of joint surfaces, degree of comminution, size and spatial relationship of fragments, and presence of intra-articular fragments. Computerized reconstruction of sagittal and coronal views at desired levels duplicates polytomography and renders standard tomography unnecessary. Radiation exposure required for a CT examination of the pelvis is equal to or less than that required for a polytomography study. CT can be utilized as a valuable diagnostic aid in the assessment of selected acetabular fractures and fracture-dislocations of the hip, providing often otherwise unobtainable information to the choice of treatment for these difficult injuries.
Forty-four patients sustaining blunt trauma with resultant diaphragmatic rupture during a 5 1/2-year period are presented. In 41 (93%), the diagnosis was established within 6 hours of admission. The correct diagnosis was made preoperatively in 19 patients operated on acutely (42%), in 22 (53%), ruptured diaphragm was an incidental finding at celiotomy or thoracotomy. The admission chest roentgenography, diagnostic peritoneal lavage, UGI contrast studies, and computed tomography were the most useful diagnostic aids. The transabdominal operative approach was utilized in 39 patients (89%). All patients had associated extra-abdominal injuries and 26 patients (59%) had associated intra-abdominal injuries. The mortality rate was 20.4%; early deaths were attributable to hemorrhage and severe head injury, late deaths to sepsis and progressive multiorgan failure.
Computed tomographic (CT) scanning has proved to be valuable in evaluating the head and abdomen of victims of blunt trauma; CT scans of the thorax often are obtained on patients with blunt torso trauma, but their value for this purpose is unclear. We conducted a prospective study to evaluate the role of chest CT scanning in thoracic trauma. Hemodynamically stable patients at least 18 years old with an estimated Abbreviated Injury Scale--Thorax score of 2 or greater underwent a contrast-enhanced CT scan of the chest, usually in conjunction with CT scans of the head, abdomen, or both. Thirteen patients were dead on arrival, 14 required emergency surgical procedures, and 13 were too unstable to undergo chest CT scan. Thirty-three patients were not included because they refused to participate or the protocol was not followed. Forty-six men (69%) and 21 women with a mean age of 42.7 years completed the study. Sixty-one were injured in motor vehicle crashes, four were injured in falls, and one each was injured by assault and by crushing forces. Injury Severity Scores ranged from 4 to 45, with a mean of 20.5. Four patients died (6%), three from head injury and one from multiple organ dysfunction. Chest roentgenography (CXR) was superior to CT scanning in identifying rib fractures, but CT scanning was more sensitive than CXR for pneumothorax, fluid collections, and infiltrates (p < 0.001); CT scanning also was more specific for aortic injury. Despite this quantitative superiority, the abnormalities missed by CXR but identified by CT scanning infrequently led to a change in management.(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: Computed tomography of the chest (CTC) is more sensitive than conventional roentgenography at detecting blunt thoracic injuries. Its effect on subsequent therapy remains incompletely characterized. METHODS: Nine criteria believed to represent the presence of, or the potential for, significant thoracic injuries were defined, and patients were followed prospectively. Forty consecutive patients had CTC after initial evaluation. Physiologic and anatomic findings were compared, and the effect of CTC on therapy was analyzed. RESULTS: CTC detected 76 injuries not found on plain roentgenograms, and plain roentgenograms detected 25 injuries not visible on CTC scans. Six patients had therapy changes based on CTC findings, five of which involved chest tube modification. The percentage of pulmonary contusion did not predict the need for mechanical ventilation but did correlate with physiologic contusion. CONCLUSIONS: Blunt thoracic injuries detected by CTC infrequently require immediate therapy. If immediate therapy is needed, findings will be visible on plain roentgenograms or on clinical exam. Routine CTC in blunt trauma is not recommended but may be helpful in selected cases.
OBJECTIVE: Modern surgical care must meet high standards of quality but must also be cost-effective. Critical care uses huge amounts of resources, and strategies for effective use of scarce, expensive intensive care unit beds must be implemented. Previously, we demonstrated that ancillary expenditures can be decreased without compromising care. The present study was performed to determine whether our cost-containment strategies were durable and could be extended to areas, such as chest roentgenography, where savings previously proved elusive. METHODS: Costs for laboratory tests, radiographs, and drugs were determined prospectively for all surgical intensive care unit care for a 34-month period (January 1, 1994-October 31, 1996) at an urban university center. A systematic, multidisciplinary cost-reduction program began on May 1, 1994, with emphasis on laboratory and radiographic testing and procedures and drug therapies. Calendar-year cohorts were compared by age and Acute Physiology and Chronic Health Evaluation II and III admission scores. Outcome variables were hospital mortality, days in the intensive care unit and hospital, and expenditures. Cost data were taken weekly from the hospital's clinical information system. RESULTS: All admission noncost variables were identical. There were significant reductions in intensive care unit and hospital length of stay, and there was a trend (p = 0.07) toward decreased hospital mortality. Normalized by the number of patient-days per week, arterial blood gas determinations were reduced 46% between 1994 and 1996, and nonarterial blood gas laboratory tests were reduced by 29% (both p < 0.0001). Within the latter group, electrolyte determinations decreased by 38% and serum creatinine determinations decreased by 32%. Chest roentgenograms decreased by 34%, but pharmaceutical costs decreased by a remarkable 73%. CONCLUSION: Durable reductions in physician-ordered ancillary expenditures are possible without compromising the standard of care of critically ill patients, but active management and daily reinforcement are necessary to the process. Shorter length of stay and lower costs benefit the patient, the surgeon, the intensivist, and the institution.
OBJECTIVE: Recent literature suggests that patients who undergo emergent tube thoracostomy in the field are at increased risks for complications. This study evaluates indications, complications, and effectiveness of field placement of chest tubes by an aeromedical service. METHODS: In a prospective study, 624 consecutive patients with chest injuries (Abbreviated Injury Scale score 1-6) were included. All patients were treated at the scene by a physician-staffed aeromedical service and transported by air to a Level I trauma center. Indications, clinical findings before and after chest tube insertion, and subsequent radiologic diagnosis by chest roentgenography were documented prospectively. RESULTS: Seventy-six chest tubes (50 unilateral, 13 bilateral) were inserted laterally in 63 patients (10%) by blunt dissection. Clinical findings included pneumothorax in 30 patients and hemothorax in 18 patients. In 15 patients receiving field chest tubes, neither pneumothorax nor hemothorax was confirmed. Six patients (<1%) arrived at the trauma center with unsuspected pneumothoraces and required chest tube insertion. No tension pneumothoraces escaped field detection and treatment. Four chest tubes placed in the field required repositioning in the hospital because of malfunction or malpositioning. Radiologic findings excluded intraparenchymal tube placements in all patients. No pleural infections were observed in these 63 patients during their hospital stay. No antibiotics were administered as a result of prehospital chest tube placement. CONCLUSION: Prehospital chest tube thoracostomy is safe, effective, and associated with low morbidity. Nontherapeutic chest tube placements occurred in 15 of 624 patients (2.4%); missed pneumothoraces occurred in 6 of 624 patients (<1%). Aggressive prehospital physician management of blunt chest trauma leads to an earlier treatment of potentially life-threatening injuries. Significant morbidity can be avoided by prompt pleural decompression using proper techniques.
OBJECTIVE: The description of the technique of multilevel oblique corpectomy (MOC) without fusion in the treatment of spondylotic myelopathy and radiculopathy and the analysis of the results of this technique from a series of 101 cases are presented. METHODS: MOC is performed using an anterolateral approach with control of the vertebral artery. The vertebral bodies are drilled obliquely from the lateral side toward the opposite posterolateral corner. More than half of the vertebral bodies are preserved, and no fusion procedure is required. The series of patients from 1992 through 1997 included 54 men and 47 women, with an average age of 57.9 years, who presented with myelopathy (n = 66) or radiculopathy (n = 35). MOC was realized on one to five levels from C2-C3 to C7-T1. Follow-up data were obtained by performing dynamic roentgenography, computed tomography, and magnetic resonance imaging 2 months, 1 year, and 3 years after surgery. RESULTS: The results (Japanese Orthopedic Association score) were improvement in 82% of the patients, worsening in 8%, and stabilization in 10%. Better results were observed in younger patients (<50 yr). No relation between results and duration of symptoms or number of levels could be established. One death occurred as a result of multiorgan failure. No late deterioration was observed; however, three patients with particular features showed delayed instability requiring fusion. CONCLUSION: MOC is a safe and efficient technique. It must be applied for patients with anterior compression and straight or kyphotic axis of the spine. No fusion is required regardless of the number of levels, providing there are no soft discs and there is no preoperative instability.
Between 1970 and 1997, we treated a total of 32 cleft feet in 21 patients (11 male and 10 female). We classified cases of cleft foot on the basis of the number of central ray deficiencies. Fourteen patients with 22 cleft feet were followed up for more than 1 year postoperatively (9 feet had no or one central ray deficiency, and 13 feet had two or three central ray deficiencies). The mean follow-up period was 8.8 years. The objective of this study was to evaluate the results of operative treatment of cleft foot. We evaluated the results of three methods: simple closure of the cleft, application of a double-pedicled flap, and insertion of a silicone block. Cosmetic complications, including widening of the foot, hypertrophic scarring, pigmentation of the grafted skin, and overlapping of the toes, were observed in patients with two or three central ray deficiencies. Few functional complications were observed: None of the patients experienced gait disturbances, although one patient complained of pain following walking. Roentgenography showed that the distance between the first and fifth metatarsals was 86 percent of that of the contralateral foot. When treating patients with no or one central ray deficiency, satisfactory results can be expected with simple closure of the cleft. However, in patients with two or three central ray deficiencies, it is difficult to obtain satisfactory results with simple closure of the cleft or application of a double-pedicled flap. Therefore, silicone block insertion to correct the defect is recommended when there is more than one central ray deficiency.
Roentgenography is a reliable method for detecting glass foreign bodies resulting from trauma. The density of glass in comparison to surrounding tissue almost always provides sufficient contrast for roentgenographic differentiation. This method is slightly compromised by the relative size of the foreign body and the body part being examined, but setting the roentgen ray beam for bone technic and having the patient in different positions facilitate detection of such a foreign body.
Leiomyosarcoma of the rectum is a rare malignant tumor with an incidence of 0.1%, occurring more frequently in men than in women and in the fifth, sixth, and seventh decades of life. Microscopically it has a characteristic appearance of interlaced bundles of spindle cells with abundant mitosis and cellular pleomorphism. The clinical picture is related to the presence of the rectal mass, the more frequent symptoms being constipation, rectal pain, rectal pressure, and bleeding. The rectal digital examination will demonstrate the mass which in most cases can be confirmed by rectosigmoidoscopy. The mucosa will be involved in about 30% to 50% of cases. Roentgenography is of little value because of the location of this tumor in the lower part of the rectum. Biopsy will be diagnostic. Treatment is radical excision of the tumor and, in this location, abdominoperineal resection of the rectum is usually required. Local excision is followed by a high incidence of recurrence. Prognosis is poor. Survival rates vary. Recent reports in the literature indicate survivals after AP resection from six months to 6 1/2 years.
We retrospectively and prospectively examined the clinical presentation, course of disease, and response to therapy in 63 patients whose mycobacterial isolates were identified as Runyon group III atypical mycobacteria. All of the patients except four had pulmonary disease similar to typical pulmonary tuberculosis. The others had scrofula or abxcess. There was a male predominance and whites were slightly more frequently infected in our series. Forty-six percent of the patients were from rural Oklahoma. Skin testing and chest roentgenography were important, but culture of the organism appeared to be the only productive method of distinguishing the atypical disease from typical tuberculosis. Eighty-one percent had an associated disease. The isolates showed a very high rate of primary drug resistance, and this was reflected in the difficulty in controlling the infection.
During a recent ten-year period, 20 patients were treated for nonpenetrating, small-bowel trauma requiring resection. Despite the relative infrequency of this injury, jejunoileal trauma must be suspected in all patients sustaining blunt force to the abdomen. Physical signs suggesting major intra-abdominal wounds usually occur at admission or immediately thereafter, provided the patient is alert. Patients with altered sensorium or equivocal findings should undergo diagnostic peritoneal lavage. Laboratory investigation is not helpful in detecting small-bowel wounds. Plain roentgenography is indicated, but was diagnostic in only 20% of patients in this series. The high incidence of associated injuries accounts for the substantial morbidity (70%) in this series. Early operation improves survival.
We have presented three patients who had bony expansion due to metastatic carcinoma of the prostate demonstrated by roentgenography and bone scintigraphy. Bony expansion must be differentiated from the blooming phenomenon which may occur in areas of high radioactivity. Bony expansion is not specific for Paget's disease, but also occurs in many other benign and malignant conditions.
We studied the clinical and radiologic features of five infants with a large opaque left hemithorax due to the combination of cardiomegaly and atelectasis. The causes of cardiomegaly were cardiomyopathy (two patients), congestive heart failure due to fluid overload, congenital mitral insufficiency, and idiopathic hypertrophic subaortic stenosis. In all five patients, there was initial total opacity of the left hemithorax with shift of the heart and mediastinum to the right due to the combination of cardiac enlargement and total lung collapse. The correct diagnosis may be suggested from conventional chest roentgenograms. Noninvasive supplementary studies, such as high-kilovolt roentgenography, fluoroscopy, esophagography, echocardiography, and radionuclide angiography, should be done for clarification.
For unknown reasons, manifestations of even heavy opportunistic infection in AIDS patients may be chronic and subtle. We have presented the second fully reported case of an AIDS patient with symptomatic Pneumocystis carinii pneumonia in whom the usual screening tests of blood gases and chest roentgenography were normal to all observers. Diffusing capacity for carbon monoxide can be an early and sensitive indication of PCP.