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Radiographic and clinical characterization of coracoid fractures: a retrospective cohort analysis

Ben-Ari, Erel; Pines, Yaniv; Gordon, Dan; Zuckerman, Joseph D; Petchprapa, Catherine; Virk, Mandeep S
PURPOSE/OBJECTIVE:Coracoid fracture is a rare injury. The aim of this study is to present the demographics, clinical and radiologic characteristics, and outcomes of coracoid fracture in a cohort of 32 patients. METHODS:We queried our institutional electronic medical record database (years 2012-2020) to identify patients with coracoid fractures using specific International Classification of Disease-10 codes. Demographic data, injury details including mechanism of injury and associated injuries, imaging performed, and treatment outcomes were obtained from retrospective chart review. A radiologist reviewed all available imaging studies (radiographs/CT/MRI) and classified the fractures according to Ogawa and Eyres classifications. Missed diagnoses were determined by comparing initial imaging reports with the follow-up imaging obtained in the office. RESULTS:Thirty-two patients with coracoid fractures were identified during the study period. Sixteen fractures (50%) occurred in the setting of low-energy trauma. Twelve fractures were missed on initial radiographs, and diagnosis with three-view radiographs (AP, scapular-Y and axillary) was 88% compared to 33% (p < 0.03) with two views (AP, scapular-Y). The majority of fractures were non-displaced (94%), and 56% were Ogawa Type-II fractures. Associated injuries were seen in 81% of patients. Most fractures (94%) were treated without surgery with excellent outcomes. CONCLUSION/CONCLUSIONS:Coracoid fractures continue to be a rare injury. In contrast to previous studies, in this case series of 32 patients, half of the fractures were associated with low-energy trauma, which correlated with higher percentage of non-displaced fractures and Ogawa Type-II fractures. Addition of the axillary view in the trauma radiographic series significantly improved the initial fracture detection rate. LEVEL IV/UNASSIGNED:Retrospective study.
PMID: 34628533
ISSN: 1633-8065
CID: 5027112

Wrist angle measurements in predicting the presence of a displaced scaphoid fracture

Becker, Jacob; Luria, Shai; Huang, Shengnan; Petchprapa, Catherine; Wollstein, Ronit
PURPOSE/OBJECTIVE:Early diagnosis and treatment of scaphoid fractures is critical to achieve union and prevent wrist degenerative arthritis. Plain radiographic measurements can guide the early approach to suspected fractures. Specifically, the ability to predict fracture or fracture stability from plain radiographs may allow the traumatologist to expand initial referral to three-dimensional imaging. We evaluated the ability of four measured angles to predict presence of a scaphoid fracture and stability. METHODS:Fifty patients with a scaphoid fracture and 50 patients without fracture were evaluated for the cortical ring sign, scapho-lunate gapping, lateral scapholunate (SL), radio-scaphoid (RS), radio-lunate (RL), and radio-capitate (RC) angles by two-blinded observers. RESULTS:Measurement of an increased SL interval was associated with the presence of a scaphoid fracture as diagnosed on three-dimensional imaging [odds ratio (OR) 3.0, confidence interval (CI) 1.53-5.87, p =  < 0.01]. The measured RL angle was associated with fracture displacement (OR 1.13, 95% CI 1.02-1.25, p = 0.02). CONCLUSIONS:Scapholunate gapping on plain radiographs in the context of a clinically suspected scaphoid fracture should increase suspicion for a fracture and may prompt earlier 3-dimensional imaging, while the presence of an abnormal radiolunate angle should increase wariness for instability and can be used in preoperative planning.
PMID: 36303041
ISSN: 1432-1068
CID: 5387462

Nerve Imaging in the Wrist

Daniels, Steven P; De Tolla, Jadie E; Azad, Ali; Petchprapa, Catherine N
Neuropathic symptoms involving the wrist are a common clinical presentation that can be due to a variety of causes. Imaging plays a key role in differentiating distal nerve lesions in the wrist from more proximal nerve abnormalities such as a cervical radiculopathy or brachial plexopathy. Imaging complements electrodiagnostic testing by helping define the specific lesion site and by providing anatomical information to guide surgical planning. This article reviews nerve anatomy, normal and abnormal findings on ultrasonography and magnetic resonance imaging, and common and uncommon causes of neuropathy.
PMID: 35609575
ISSN: 1098-898x
CID: 5283882

A Preliminary Model of the Wrist Midcarpal Joint

Pendola, Martin; Petchprapa, Catherine; Wollstein, Ronit
PMID: 34881108
ISSN: 2163-3916
CID: 5079312

The smoke sign: a secondary sign of unsuspected acute pectoralis major tendon injury on routine shoulder MRI

Petchprapa, Catherine N; Vaswani, Devin; Garwood, Elisabeth; Samim, Mohammad; Bencardino, Jenny T
OBJECTIVE:To study the diagnostic utility of the "smoke sign" to detect unsuspected acute pectoralis major tendon injury on routine shoulder MRI. MATERIALS AND METHODS/METHODS:Retrospective study of 52 shoulder MRI in patients with (38) and without (14) acute pectoralis major injury confirmed on imaging. Two readers independently reviewed shoulder MRI for the presence of the "smoke sign"-feathery soft tissue edema lateral or anterior to short head biceps/coracobrachialis on fluid-sensitive coronal-oblique and sagittal-oblique images, respectively. RESULTS:The smoke sign was present on shoulder MRI in 24/24 (100%) humeral avulsions, 4/4 (100%) tendon tears, 4/8 (50%) of myotendinous junction injuries, and 0/2 (0%) intramuscular injuries. The smoke sign was present in 0/14 examinations without acute pectoralis major injury. CONCLUSION/CONCLUSIONS:While dedicated pectoralis MRI remains the preferred method for imaging pectoralis injury, the "smoke sign" can serve as an easy to recognize finding on routine shoulder MRI that can raise the suspicion of an acute pectoralis major tendon injury. Its detection should prompt evaluation of the pectoralis major tendon and recommendation for dedicated imaging to confirm and evaluate the full extent of injury.
PMID: 33733695
ISSN: 1432-2161
CID: 4818002

Palmar Musculature: Does It Affect the Development of Carpal Tunnel Syndrome? A Pilot Study

Simcox, Trevor; Seo, Lauren; Dunham, Kevin; Huang, Shengnan; Petchprapa, Catherine; Wollstein, Ronit
PMID: 34109061
ISSN: 2163-3916
CID: 5017942

Translation of 2-Dimensional Wrist Radiographic Measurements to 3-Dimensional CT Scans

Wollstein, Ronit; Kramer, Aviv; Babb, James; Petchprapa, Catherine
Background: Anatomical structure affects function. The morphology of articulations dictates the way forces will travel through the joint. A better understanding of the structure and function of the wrist will enhance our ability to diagnose and treat wrist conditions. Two wrist types have been described based on the morphology of the midcarpal joint. Biomechanically it is important to see if these 2-dimensional (2D) observations reflect articular contact areas. Our purpose was to assess the correlation between measurements performed on wrist radiographs (2D) to measurements performed on 3-dimensional (3D) computed tomography (CT). Methods: Retrospective review of a database of normal wrist radiographs and corresponding normal CT scans. Only imaging pairs with normal carpal alignment and technically optimal imaging were included. Evaluations included lunate, capitate and wrist type, capitate circumference, percent capitate circumference and volume that articulates with the lunate, scapholunate ligament, scaphoid, hamate, trapezoid, base of the index and middle and ring metacarpal bones. Results: Midcarpal joint radiographic measurements were positively correlated with measurements on CT scans. Correlations were 0.51 for capitate type and 0.71 for lunate type with both p < 0.001. Percent contact of the lunate with the hamate: r was 0.74 p < 0.001. Using logistic regression analysis, percent lunate-hamate contact on CT was a significant predictor of radiographic lunate type 2 p < 0.001. Percent contact area between lunate and hamate > 7.8% on CT scan achieved a sensitivity of 100% and specificity 79.4% for a type 2 lunate. Conclusions: 1) Good correlations found between CT and plain radiographs in lunate type, capitate type, and midcarpal joint contact support the use of plain radiographs to describe contact between the carpal bones in the clinical setting. 2) The retrospective nature of this study limited the technical quality of the measurements. Volumetric analysis may aid in a more exact evaluation of surface contact area.
PMID: 32723043
ISSN: 2424-8363
CID: 4581162

Human T cell lymphotropic virus type-1 associated lymphoma presenting as an intramuscular mass of the calf

Gorelik, Natalia; T Hoda, Syed; Petchprapa, Catherine; Liu, Cynthia; Adler, Ronald
Adult T cell leukemia/lymphoma (ATLL) is a mature T cell neoplasm caused by the human oncogenic retrovirus human T lymphotropic virus type-1 (HTLV-1). While several musculoskeletal manifestations have been described in ATLL, skeletal muscle involvement is unusual, with only four cases reported in the English-language literature. We present a rare case of ATLL manifesting as an intra-muscular calf mass in a 58-year-old man who immigrated to the USA from West Africa. While skeletal muscle involvement by lymphoma is uncommon, it remains important to consider within the differential diagnosis when there are suggestive imaging findings because it entails important technical biopsy considerations as well as treatment implications. This case report also raises awareness of ATLL presenting outside of typical HTLV-1 endemic areas, related to current population migration patterns. ATLL should therefore be considered in patients with appropriate risk factors.
PMID: 32076761
ISSN: 1432-2161
CID: 4313262

MRI of the Fingers: An Update

Petchprapa, Catherine N; Vaswani, Devin
OBJECTIVE. The purpose of this article is to review the general guidelines for MRI of the finger and emphasize normal finger anatomy as it relates to abnormalities and injuries. CONCLUSION. Advanced imaging, particularly MRI, is increasingly relied on to make the diagnosis and guide management of finger injuries. It is incumbent on radiologists to understand the complex anatomy of the fingers as well as to be familiar with common injuries and aspects of injuries that affect management in order to meaningfully contribute to patient care.
PMID: 31268729
ISSN: 1546-3141
CID: 3968172

The smoke sign: A sign of pectoralis tendon humeral insertional injury on routine shoulder mri [Meeting Abstract]

Vaswani, D; Petchprapa, C; Garwood, E; Samim, M; Bencardino, J
Purpose: Study the diagnostic accuracy of the 'smoke sign' on routine shoulder MR examinations for detection of pectoralis tendon humeral insertional injury.
Material(s) and Method(s): IRB approved, HIPAA compliant study. Radiology database queried for MR with reports containing 'pectoralis' and 'shoulder' from 9/2012 to 7/2018. Patients without prior pectoralis surgery with shoulder and pectoralis MR within 4 months, and shoulder MRpositive for pectoralis injury based on report and imaging review that clearly depicted pectoralis injury were included. Anonymized, randomized shoulder MR reviewed independently by two musculoskeletal fellowship-trained radiologists for 'smoke sign' on coronal- and sagittal-oblique sequences. Teaching session provided guidelines for smoke sign (ill-defined edema lateral or anterior to short head biceps/ coracobrachialis on coronal- and sagittal-oblique fluid-sensitive images, respectively) before reader review. AllMR reviewed by senior author for presence and location of pectoralis injury.
Result(s): 52 shoulder MR exams total: 33 patients with shoulder and pectoralis MR, 4 patients with shoulder MR and pectoralis imaging on same exam, 15 patients with shoulder MR only.14/52 exams didn't have pectoralis injury on shoulder or pectoralis MR; 'smoke sign' was present in none of these cases. Remaining 38 patients had pectoralis injuries; 24/38 (humeral avulsion), 4/38 (tendon tear) 8/38 (myotendinous junction), 2/38 (intramuscular injury). Pooled sensitivity, specificity, negative and positive predictive value for 'smoke sign' was 86%, 100%, 76% and 100%. When only tendon tears and avulsions were assessed, this rose to 100%, 100%, 100% and 100%. Kappa coefficient was 0.922 for the presence of the sign on coronal oblique 0.876 on sagittal oblique images. Smoke sign was present in all 8 surgically proven pectoralis injuries.
Conclusion(s): 'Smoke sign' is sensitive and specific for pectoralis humeral insertional injury, especially tendon tears and avulsions. Detection of this sign on routine shoulder MR should prompt careful evaluation of the distal pectoralis tendon and recommendation for dedicated pectoralis imaging
ISSN: 0364-2348
CID: 3690382