Faculty Bibliography

Chest, abdominal, and groin pain are common patient complaints that can be due to a variety of causes. Once potentially life-threatening visceral causes of pain are excluded, the evaluation should include musculoskeletal sources of pain from the body wall and core muscles. Percutaneous musculoskeletal procedures play a key role in evaluating and managing pain, although most radiologists may be unfamiliar with applications for the body wall and core muscles. US is ideally suited to guide these less commonly performed procedures owing to its low cost, portability, lack of ionizing radiation, and real-time visualization of superficial soft-tissue anatomy. US provides the operator with added confidence that the needle will be placed at the intended location and will not penetrate visceral or vascular structures. The authors review both common and uncommon US-guided procedures targeting various portions of the chest wall, abdominal wall, and core muscles with the hope of familiarizing radiologists with these techniques. Procedures include anesthetic and corticosteroid injection as well as platelet-rich plasma injection to promote tendon healing. Specific anatomic structures discussed include the sternoclavicular joint, costochondral joint, interchondral joint, intercostal nerve, scapulothoracic bursa, anterior abdominal cutaneous nerve, ilioinguinal nerve, iliohypogastric nerve, genitofemoral nerve, pubic symphysis, common aponeurotic plate, and adductor tendon origin. Relevant US anatomy is depicted with MRI correlation, and steps to performing successful safe US-guided injections are discussed. Confidence in performing these procedures will allow radiologists to continue to play an important role in diagnosis and management of many musculoskeletal pathologic conditions. ^©RSNA, 2021.

Medial and lateral elbow pain are often due to degenerative tendinosis and less commonly due to trauma. The involved structures include the flexor-pronator tendon origin in medial-sided pain and the extensor tendon origin in lateral-sided pain. Multimodality imaging is often obtained to verify the clinically suspected diagnosis, evaluate the extent of injury, and guide treatment decisions. Image-guided procedures can provide symptom relief to support physical therapy and also induce tendon healing. Surgical debridement and repair are typically performed in refractory cases, resulting in good to excellent outcomes in most cases. In this article, we review and illustrate pertinent anatomical structures of the distal humerus, emphasizing the structure and contributions of the flexor-pronator and extensor tendon origins in acute and chronic tendon abnormalities. We also discuss approaches to image-guided treatment and surgical management of medial and lateral epicondylitis.

Magnetic resonance imaging provides a comprehensive evaluation of the shoulder including the rotator cuff muscles and tendons, glenoid labrum, long head biceps tendon, and glenohumeral and acromioclavicular joint articulations. Most institutions use two-dimensional sequences acquired in all three imaging planes to accurately evaluate the many important structures of the shoulder. Recently, the addition of three-dimensional (3D) acquisitions with 3D reconstructions has become clinically feasible and helped improve our understanding of several important pathologic conditions, allowing us to provide added value for referring clinicians. This article briefly describes techniques used in 3D imaging of the shoulder and discusses applications of these techniques including measuring glenoid bone loss in anterior glenohumeral instability. We also review the literature on routine 3D imaging for the evaluation of common shoulder abnormalities as 3D imaging will likely become more common as imaging software continues to improve.

OBJECTIVE:To present our experience with contrast-enhanced ultrasound (CEUS)-guided musculoskeletal soft tissue biopsies in a busy interventional clinic. MATERIALS AND METHODS/METHODS:After IRB approval was obtained and informed consent was waived, we retrospectively reviewed all CEUS-guided musculoskeletal biopsies performed from December 1, 2018 to March 2, 2020. Relevant pre-procedure imaging was reviewed. Number of samples, suspected necrosis on pre-procedure imaging, specimen adequacy for pathologic analysis, correlation with pathologic diagnosis of surgical resection specimens, and procedural complications were recorded. RESULTS:Thirty-six CEUS-guided musculoskeletal biopsies were performed in 32 patients (mean age 57, range 26-88; 22 males, 10 females). All procedures were performed using 16-gauge biopsy needles, and all procedures provided adequate samples for pathologic analysis as per the final pathology report. Between two and seven core specimens were obtained (mean 3.7). In 30/36 cases (83%), a contrast-enhanced MRI was obtained prior to biopsy, and 10/30 (33%) of these cases showed imaging features suspicious for necrosis. In 15/36 cases, surgical resection was performed, and the core biopsy and surgical resection specimens were concordant in 14/15 cases (93%). One patient noted transient leg discomfort at the time of microbubble bursting. Otherwise, no adverse reactions or procedural complications were observed. CONCLUSION/CONCLUSIONS:CEUS is an accurate way to safely target representative areas of soft tissue lesions for biopsy and can be implemented in a busy interventional clinic. Our early experience has shown this to be a promising technique, especially in targeting representative areas of heterogeneous lesions and lesions with areas of suspected necrosis on prior imaging.

Chronic groin pain can be due to a variety of causes and is the most common complication of inguinal hernia repair surgery. The etiology of pain after inguinal hernia repair surgery is often multifactorial though injury to or scarring around the nerves in the operative region, namely the ilioinguinal nerve, genital branch of the genitofemoral nerve, and the iliohypogastric nerve, is thought to be a key factor in causing chronic post-operative hernia pain or inguinal neuralgia. Inguinal neuralgia is difficult to treat and requires a multidisciplinary approach. Radiologists play a key role in the management of these patients by providing accurate image-guided injections to alleviate patient symptoms and identify the pain generator. Recently, ultrasound-guided microwave ablation has emerged as a safe technique, capable of providing durable pain relief in the majority of patients with this difficult to treat condition. The objectives of this paper are to review the complex nerve anatomy of the groin, discuss diagnostic ultrasound-guided nerve injection and patient selection for nerve ablation, and illustrate the microwave ablation technique used at our institution.

Ulnar collateral ligament (UCL) reconstruction is now being performed more commonly and on younger patients than in prior decades. As a result, radiologists will increasingly be asked to evaluate elbow imaging of patients presenting with pain who have had UCL reconstruction. It is essential for radiologists to understand the normal and abnormal imaging appearances after UCL reconstruction and ulnar nerve transposition, which is also commonly performed in overhead-throwing athletes. Doing so will allow radiologists to provide accurate interpretations that appropriately guide patient management.

Scurvy is a rare disease in developed nations. In the field of pediatrics, it primarily is seen in children with developmental and behavioral issues, malabsorptive processes, or diseases involving dysphagia. We present the case of an otherwise developmentally appropriate 4-year-old boy who developed scurvy after gradual self-restriction of his diet. He initially presented with a limp and a rash and was subsequently found to have anemia and hematuria. A serum vitamin C level was undetectable, and after review of the MRI of his lower extremities, the clinical findings supported a diagnosis of scurvy. Although scurvy is rare in developed nations, this diagnosis should be considered in a patient with the clinical constellation of lower-extremity pain or arthralgias, a nonblanching rash, easy bleeding or bruising, fatigue, and anemia. This case highlights the importance of carefully assessing a child's dietary and developmental status at well-child visits, which can help avoid a more invasive workup.

We present two cases of atraumatic costal cartilage fracture secondary to violent coughing. Although costal cartilage fractures due to trauma and bony rib fractures due to violent coughing have been described, to our knowledge there have been no prior reported cases of cough-induced costal cartilage fracture. It is important for radiologists to consider costal cartilage fractures, which are often more subtle than osseous injuries, in patients with chest pain, and understand that they may not always be preceded by direct trauma. Identifying this injury is clinically important and will prevent patients from undergoing unnecessary examinations to rule out a cardiac cause of chest pain or a pulmonary embolism.