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Pediatric versus adult magnetic resonance imaging patterns in acute high ankle sprains

Walter, William R; Alaia, Erin F; Samim, Mohammad; Rosenberg, Zehava S
BACKGROUND:There is a paucity of literature describing MRI patterns of high ankle sprains in pediatric patients. Radiologists should understand MRI patterns of these injuries in both adults and children. OBJECTIVE:To describe normal MRI appearance of pediatric syndesmotic ligaments and compare MRI patterns of high ankle sprains in children versus adults. MATERIALS AND METHODS/METHODS:We reviewed consecutive ankle MRIs performed over 3 years and divided them into three cohorts: a normal pediatric (≤16 years) cohort, and pediatric and adult cohorts with acute/subacute ankle syndesmosis injuries. Our retrospective review assessed interobserver agreement (Cohen kappa coefficient) and normal pediatric syndesmotic anatomy. We compared patterns of high ankle sprains (Fisher exact test) including ligament tears, periosteal stripping, avulsions and fractures. RESULTS:Of the 582 ankle MRIs, we included 25 in the normal pediatric cohort, 20 in the pediatric injury cohort and 23 in the adult injury cohort. The anterior and posterior tibiofibular ligaments all attached to cortex or cartilaginous precursor, while the interosseous ligament/membrane complex attached to the fibrous periosteum in 22/25 (88%) normal pediatric cases. Tibial periosteal stripping at the interosseous ligament/membrane complex attachment occurred in 7/20 (35%) pediatric and 1/23 (4%) adult injury cases (P=0.02). No other statistically significant differences were found. Interobserver agreement ranged from kappa=0.46 to kappa=0.82 (ligament tears), 0.38 to 0.45 (avulsions) and 0.69 to 0.77 (periosteal stripping). CONCLUSION/CONCLUSIONS:The normal interosseous ligament/membrane complex typically attaches to fibrous periosteum rather than bony cortex. Tibial periosteal stripping, usually without tibial fracture, is significantly more common among pediatric high ankle sprains. MRI patterns of high ankle sprains are otherwise not significantly different between children and adults.
PMID: 34009406
ISSN: 1432-1998
CID: 4888742

Fibular Tip Periostitis: New Radiographic Sign Predictive of Chronic Peroneal Tendon Subluxation-Dislocation in Pes Planovalgus

Abballe, Valentino D; Samim, Mohammad; Gavilá, Elisa Ramos; Walter, William R; Alaia, Erin F; Rosenberg, Zehava Sadka
PMID: 32936017
ISSN: 1546-3141
CID: 5003542

Pitfalls in MRI of the Developing Pediatric Ankle

Walter, William R; Goldman, Lauren H; Rosenberg, Zehava S
Normal skeletal development in the pediatric ankle is dynamic and often produces variable imaging appearances that are subject to misinterpretation. Radiologists must understand the underlying developmental phenomena, such as endochondral and membranous ossification and physeal fusion, and be familiar with their common and uncommon imaging manifestations unique to the pediatric ankle. This is especially true as the use of MRI in the evaluation of musculoskeletal trauma expands among younger populations. The authors focus on MRI evaluation of the skeletally maturing pediatric ankle and present pearls for accurately distinguishing normal findings and imaging pitfalls from true pathologic findings. The normal but often variable imaging findings of preossification, secondary ossification, and multiple ossification centers, as well as the range of bone marrow signal intensities that can be visualized within ossification centers, are described, along with tips to help differentiate these from true pathologic findings such as contusion, fracture, or tumor. The authors also review dynamic periosteal and physeal contributions to bone growth to highlight helpful distinguishing features and avoid misdiagnosis of common subperiosteal and periphyseal abnormalities. For example, the normal trilaminar appearance of the immature cortex and periosteum should not be mistaken for periosteal reaction, traumatic stripping, or subperiosteal hematoma. In addition, the physis can have several confusing but normal appearances, including normal physeal undulations (eg, Kump bump) or focal periphyseal edema, which should not be mistaken for pathologic findings such as physeal fracture, infection, or bar. ©RSNA, 2020.
PMID: 33216674
ISSN: 1527-1323
CID: 4702252

Radiographic features and complications following coracoclavicular ligament reconstruction

Kennedy, Brian P; Rosenberg, Zehava Sadka; Alaia, Michael J; Samim, Mohammad; Alaia, Erin F
OBJECTIVE:To report radiographic features and complications of coracoclavicular ligament reconstruction and the association of radiographic features with symptomatology. MATERIALS AND METHODS/METHODS:Retrospective picture archiving and communication system query (1/2012-8/2018) identified subjects with prior coracoclavicular ligament reconstruction. Post-operative radiographs were reviewed with attention to the following: (1) acromioclavicular alignment, (2) coracoclavicular width, (3) distal clavicular osteolysis, (4) osseous tunnel widening, and (5) hardware complication or fracture. Medical records were reviewed to determine purpose of imaging follow-up (symptomatic versus routine). Statistical analysis determined associations between binary features and outcomes, and inter-reader agreement. RESULT/RESULTS:Review of 55 charts identified 32 subjects (23 male, 9 females; age range 24-64; imaged 1-34 months following surgery) meeting inclusion criteria. Loss of acromioclavicular reduction was the most common imaging finding (n = 25, 78%), with 76% progressing to coracoclavicular interval widening. Distal clavicular osteolysis was seen in 21 cases (66%) and was significantly associated with loss of acromioclavicular joint reduction (p = 0.032). Tunnel widening occurred in 23 patients (82%) with more than one follow-up radiograph. Six (19%) had hardware complication or fracture. No radiographic feature or complication had significant correlation with symptomatology (p values 0.071-0.721). Inter-reader agreement was moderate to substantial for coracoclavicular interval widening and hardware complication, fair to substantial for tunnel widening, and fair to moderate for loss of acromioclavicular reduction and distal clavicular osteolysis. CONCLUSION/CONCLUSIONS:Loss of acromioclavicular joint reduction, coracoclavicular interval widening, distal clavicular osteolysis, and tunnel widening are common radiographic features after coracoclavicular ligament reconstruction; however, they do not necessarily correlate with symptomatology.
PMID: 31925463
ISSN: 1432-2161
CID: 4257832

Anteroposterior Radiograph of the Ankle with Cross-Sectional Imaging Correlation

Lin, Dana J; Alaia, Erin F; Rossi, Ignacio Martín; Zember, Jonathan; Rosenberg, Zehava Sadka
The focus of this article is to illustrate various pathologic entities and variants, heralding disease about the ankle, based on scrutiny of AP radiographs of the ankle, with correlative findings on cross-sectional imaging. Many of these entities can only be detected on the AP ankle radiograph and, if not recognized, may lead to delayed diagnosis and persistent morbidity to the patient. However, a vigilant radiologist, equipped with the knowledge of the characteristic appearance and typical locations of the imaging findings, should be able to make the crucial initial diagnosis and surmise additional findings to be confirmed on cross-sectional imaging.
PMID: 31575401
ISSN: 1557-9786
CID: 4115642

Normal development imaging pitfalls and injuries in the pediatric shoulder

Zember, Jonathan; Vega, Pedro; Rossi, Ignacio; Rosenberg, Zehava Sadka
The skeletal maturation of the shoulder has been well documented on radiographic and cadaveric studies. Recent increased use of MRI has provided increased understanding of the soft-tissue and osseous changes that occur during development. Thus recognizing normal maturation, imaging manifestations and pitfalls is crucial when evaluating the pediatric shoulder joint. At birth, the humeral diaphysis, midportion of the clavicle, and the body of the scapula are ossified, while the remainder of the bones of the shoulder are composed of non-ossified cartilaginous precursors. During growth, cartilaginous apophyses and epiphyses of the shoulder develop numerous secondary ossification centers, which fuse with the primary ossification centers to form the complete bony components of the shoulder. Additionally changes in the morphology of the growth plates as well as marrow signal occur in an organized manner. This paper affords the reader with an understanding of the normal development of three major components of skeletal maturation in the shoulder: ossification centers, growth plates and marrow signal. These topics are further subdivided into the glenoid, proximal humerus and acromioclavicular joint. We also provide a focus on distinguishing normal anatomy from imaging pitfalls related to skeletal maturation.
PMID: 31686168
ISSN: 1432-1998
CID: 4179262

Stener-Like Lesions of the Superficial Medial Collateral Ligament of the Knee: MRI Features

Alaia, Erin F; Rosenberg, Zehava Sadka; Alaia, Michael J
OBJECTIVE. The purpose of this article is to describe Stener-like lesions of the superficial medial collateral ligament (sMCL) of the knee, which, to our knowledge, have not yet been reported in the radiologic literature. This lesion, defined as a distal tear with interposition of osseous or soft-tissue structures between the ligament and its tibial attachment, often requires surgical intervention. MATERIALS AND METHODS. Knee MRI examinations of grade 3 sMCL tears were identified via a search of department imaging and orthopedic case files of medial collateral ligament (MCL) tears for the period of January 2010-April 2017 using the keywords "complete MCL tear" or "near complete MCL tear." Two musculoskeletal radiologists reviewed the MRI examinations. The location of the sMCL tear, presence of a Stener-like lesion, associated ligamentous injuries, and surgical findings were recorded. RESULTS. Review of 65 knee MRI examinations identified 20 cases of distal tibial grade 3 sMCL tear. Of the distal tears, 12 (60%) were Stener-like lesions and six (30%) were borderline lesions. Of these 18 cases, 14 (78%) were associated with multiligament knee injury and nine (50%) underwent MCL repair or reconstruction. Ten of the 12 (83%) Stener-like lesions were displaced superficial to the pes anserinus and two (17%) were entrapped, one in a reverse Segond fracture and one in the femorotibial compartment. CONCLUSION. Stener-like lesions represent a high percentage of tibia-sided sMCL avulsions, are found most often with pes anserinus interposition, and are frequently associated with multiligamentous injury, suggesting high-energy trauma. MRI diagnosis is important because interposition preventing anatomic healing and potential secondary valgus instability often prompt surgical intervention.
PMID: 31461317
ISSN: 1546-3141
CID: 4054482

Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer

Walter, William R; Hirschmann, Anna; Alaia, Erin F; Tafur, Monica; Rosenberg, Zehava S
The midtarsal (Chopart) joint complex consists of the talonavicular and calcaneocuboid joints and their stabilizing ligaments. Detailed assessment of this complex at MRI can be challenging owing to frequent anatomic variation and the small size of the structures involved. Nevertheless, a wide spectrum of pathologic conditions affect the joint complex, and its imaging evaluation deserves more thorough consideration. This review focuses on MRI evaluation of normal ligamentous anatomy and common variations about the Chopart joint, presenting practical imaging tips and potential diagnostic pitfalls. Imaging findings across a spectrum of traumatic Chopart joint injuries are also reviewed, from midtarsal sprains to Chopart fracture-dislocations. Midtarsal sprains-commonly associated with ankle inversion injuries-are emphasized, along with their often predictable radiographic and MRI injury patterns. Online DICOM image stacks are available for this article. ©RSNA, 2018.
PMID: 30500305
ISSN: 1527-1323
CID: 3573482

Imaging of Chopart (Midtarsal) Joint Complex: Normal Anatomy and Posttraumatic Findings

Walter, William R; Hirschmann, Anna; Tafur, Monica; Rosenberg, Zehava S
OBJECTIVE:The objective of this article is to review the normal anatomy and posttraumatic findings of the Chopart joint complex. Key imaging features of the normal ligaments and patterns of ligamentous and osseous injuries are discussed. CONCLUSION/CONCLUSIONS:Traumatic midtarsal injuries, particularly midtarsal sprain, are often overlooked clinically and on imaging but are relatively common and typically are associated with inversion ankle injuries. Radiologists should be familiar with Chopart joint anatomy and the imaging features of midtarsal injuries because early diagnosis may help optimize clinical management.
PMID: 29927330
ISSN: 1546-3141
CID: 3158272

Acute Fracture of the Anterior Process of Calcaneus: Does It Herald a More Advanced Injury to Chopart Joint?

Hirschmann, Anna; Walter, William R; Alaia, Erin F; Garwood, Elisabeth; Amsler, Felix; Rosenberg, Zehava S
OBJECTIVE:Injuries at the calcaneocuboid and talonavicular joint have been described as two distinct, unrelated entities in the radiology literature. Our purpose was to assess the coexistence of these injuries using radiography and MRI and to correlate our findings with radiologic and clinical diagnoses. MATERIALS AND METHODS/METHODS:Twenty-one patients with injury at the anterior calcaneal process on radiographs or MR images were retrospectively assessed for concomitant injury at the talonavicular joint. Radiologic and clinical diagnoses and treatment were documented. McNemar and kappa statistics were calculated; p values < 0.05 were considered statistically significant. RESULTS:Radiographic and MRI rates of detection of injuries across the Chopart joint were statistically different. Calcaneocuboid avulsion fractures were evident on 48% of radiographs and 100% of MR images (p = 0.001). Talonavicular joint injuries were evident on 38% of radiographs and 76% of MR images (p = 0.008). Concomitant injury at both joints was evident on 14% of radiographs and 76% of MR images (p < 0.0001). Interrater agreement was 0.488-0.637 and 0.286-0.364 for talonavicular and 0.144-0.538 and 0.976-1 for calcaneocuboid injuries on radiography and MRI, respectively. Sixty percent of calcaneocuboid fractures were prospectively missed on radiography (none on MRI), whereas 38% and 25% of talonavicular findings were missed on radiography and MRI, respectively. Sixty percent of injuries were clinically misdiagnosed as ankle sprains. Chopart joint injury was never mentioned in prospective clinical or imaging diagnoses. CONCLUSION/CONCLUSIONS:Calcaneocuboid and talonavicular injuries commonly coexist. Radiographs underestimate severity of injury; MR images show more subtle abnormalities. Lack of mention of Chopart joint injury clinically and on imaging reports underlies the need for greater familiarity with this entity.
PMID: 29570372
ISSN: 1546-3141
CID: 3001562