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PURPOSE: Ipsilateral femoral neck fractures can be seen alongside femoral shaft fractures in high-velocity trauma patients. These neck fractures are often occult on radiographs and CT, and can have a significant impact on patient outcomes if not treated promptly. Limited protocol pelvic MRI has been used to increase sensitivity for these occult fractures. Detailed characterization of these fractures on MRI is lacking. METHODS: 427 consecutive trauma patients presenting to our emergency department who had known femoral diaphyseal fractures but no ipsilateral femoral neck fracture on radiographs or CT were included in this study. These patients were scanned using a limited protocol MRI with coronal T1 and coronal STIR sequences. Presence of an ipsilateral femoral neck fracture and imaging characteristics of the fracture were obtained. RESULTS: 31 radiographically occult ipsilateral femoral neck fractures were found, representing 7% of all cases. All neck fractures were incomplete. All fractures originated along the lateral cortex of the femoral neck and extended medially towards the junction of the medial femoral neck and the lesser trochanter. 58% (18/31) were vertical in orientation. 61% (19/31) did not demonstrate any appreciate edema on STIR images. CONCLUSION: Implementation of limited protocol MRI protocol increases sensitivity for detection of femoral neck fractures in the setting of ipsilateral femoral shaft fractures not seen on radiograph or CT imaging. We describe the characteristic MR imaging features of these fractures.

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BACKGROUND: AI/ML CAD tools can potentially improve outcomes in the high-stakes, high-volume model of trauma radiology. No prior scoping review has been undertaken to comprehensively assess tools in this subspecialty. PURPOSE: To map the evolution and current state of trauma radiology CAD tools along key dimensions of technology readiness. METHODS: Following a search of databases, abstract screening, and full-text document review, CAD tool maturity was charted using elements of data curation, performance validation, outcomes research, explainability, user acceptance, and funding patterns. Descriptive statistics were used to illustrate key trends. RESULTS: A total of 4052 records were screened, and 233 full-text articles were selected for content analysis. Twenty-one papers described FDA-approved commercial tools, and 212 reported algorithm prototypes. Works ranged from foundational research to multi-reader multi-case trials with heterogeneous external data. Scalable convolutional neural network-based implementations increased steeply after 2016 and were used in all commercial products; however, options for explainability were narrow. Of FDA-approved tools, 9/10 performed detection tasks. Dataset sizes ranged from < 100 to > 500,000 patients, and commercialization coincided with public dataset availability. Cross-sectional torso datasets were uniformly small. Data curation methods with ground truth labeling by independent readers were uncommon. No papers assessed user acceptance, and no method included human-computer interaction. The USA and China had the highest research output and frequency of research funding. CONCLUSIONS: Trauma imaging CAD tools are likely to improve patient care but are currently in an early stage of maturity, with few FDA-approved products for a limited number of uses. The scarcity of high-quality annotated data remains a major barrier.

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Osteoarthritis (OA) is one of the most common diseases worldwide and is expected to increase in incidence as the age of the general population rises. Both oral medications, such as NSAIDs, and surgical treatments used for OA management have limitations. Demand is rising for minimally invasive techniques such as intraarticular injections and percutaneous interventions for use in place of or in conjunction with oral medications and surgical therapies, and the past 2 decades have seen a rapid expanse in both pharmacologic and nonpharmacologic minimally invasive OA treatments. Image guidance with fluoroscopy, CT, or ultrasound is often used in conjunction with these procedures to achieve precise treatment localization to achieve maximal therapeutic effect. The choice of modality used for image guidance is often influenced by clinician experience, patient characteristics, and equipment availability. This article reviews the mechanisms of action, contraindications, complications, and efficacy of conventional and developing minimally invasive OA treatments. The minimally invasive treatment options described in this Review include therapeutic injections such as antiinflammatory agents, viscosupplements, and biologics, as well as nonpharmacologic treatments of subchondroplasty, nerve ablation, genicular artery embolization, intraarticular pulsed radiofrequency therapy, and MRI-guided focused ultrasound therapy.

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PURPOSE: To review the epidemiology, pertinent wrist anatomy, classification system, and emergent imaging evaluation of carpal instability with a focus on radiographic assessment of instability. METHODS: A review of current literature on carpal instability was performed with summary presentation of carpal instability epidemiology, carpal anatomy, imaging evaluation, and classification with imaging evaluation focused on diagnosis in the emergency setting. RESULTS: Carpal instability is a common pathology in falls on outstretched hand and is likely underdiagnosed due to instability being occult or demonstrating subtle malalignment on static imaging of the wrist. While there is a complex network of intrinsic and extrinsic ligaments contributing to carpal instability, a detailed knowledge of these ligaments is not necessary for radiologists to make an accurate diagnosis in the emergency setting, as identification and classification of carpal instability is based on identification of carpal malalignment patterns on radiography as opposed to identification of specific ligament injuries on advanced imaging. The Mayo classification is the most widely used classification system, which divides carpal instability into four categories: dissociative, non-dissociative, complex, and adaptive. Understanding this classification system allows radiologists to successfully classify almost all carpal instability injuries they will encounter, even in the setting of unusual or rare instability patterns. CONCLUSION: In working with the treating clinician, it is essential that the emergency radiologist is comfortable with identifying and classifying carpal instability. This will ensure prompt treatment of seemingly benign injuries and those that require intervention, surgical or otherwise, improving the likelihood of a good outcome.

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While pediatric cervical spine injuries (CSI) are rare, they are associated with high morbidity and mortality and sometimes require expeditious surgical management. In this article, we aim to improve the diagnostic accuracy of pediatric CSI by reviewing normal pediatric cervical anatomy, typical pediatric CSI patterns, and common mimics of pediatric CSI. A literature review was conducted on pediatric CSI, its epidemiology, and the various imaging manifestations and mimics. The most common pediatric CSI occur in the upper cervical spine owing to the higher fulcrum and larger head at a young age, namely prior to age 9 years, while lower CSI occur more frequently in patients older than 9 years. While various craniocervical measurements may be utilized to identify craniocervical disruption, soft tissue injuries may be the only manifestation, thus making pediatric CSI difficult to diagnose on initial imaging. In the acute setting, CT cervical spine is an appropriate initial imaging modality for pediatric CSI evaluation. MRI serves as an additional tool to exclude or identify injuries when initial findings are equivocal. It is essential to recognize the unique anatomy and biomechanics of the pediatric spine and thus discern common pediatric CSI patterns and their mimics.

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PURPOSE: To assess the accuracy of craniocervical measurements for identifying craniocervical injuries and the frequency of subjective findings of craniocervical injuries on CT in pediatric patients. METHODS: Case-controlled retrospective review of patients ≤ 16 years old with craniocervical junction injuries. Receiver operator curves were created for common craniocervical measurements on CT comparing patients with complete and partial craniocervical injuries to uninjured cohort. Frequency of subjective CT findings of craniocervical injury was assessed in the injured cohort. RESULTS: For complete disruption injuries (CD) (n = 27), C1-C2 distance (AUC = 0.90, 95%CI = 0.83-0.97), atlanto-occipital distance (AUC = 0.95-0.98, 95%CI = 0.90-1.00), and basion-dens distance (AUC = 0.90, 95%CI = 0.82-0.98) had excellent accuracy diagnosing injury. Powers ratio (AUC = 0.85, 95%CI = 0.76-0.94) had good, basion-posterior axial line (AUC = 0.74, 95%CI = 0.61-0.86) fair, and atlanto-dental distance (AUC = 0.69, 95%CI = 0.57-0.82) poor accuracy. For partial disruption injuries (PD) (n = 21), basion-dens distance (AUC = 0.75, 95%CI = 0.62-0.88) had fair accuracy diagnosing injury. Powers ratio (AUC = 0.63, 95%CI = 0.47-0.79), C1-C2 distance (AUC = 0.60, 95%CI = 0.45-0.75), atlanto-dental distance (AUC = 0.55, 95%CI = 0.39 = 0.71), atlanto-occipital distance (AUC = 0.63-0.65, 95%CI = 0.47-0.81), and basion-posterior axial line (AUC = 0.60, 95%CI = 0.44-0.76) all had poor accuracy. Eighty-one percent (n = 22) of CD and 38% (n = 8) of PD patients had non-concentric atlanto-occipital joints. One hundred percent of CD patients had ≥ 1 soft tissue finding and eighty-one percent (n = 22) had ≥ 2 findings. Seventy-three percent (n = 16) of PD patients had ≥ 1 soft tissue finding. Eighty-six percent (n = 18) of PD patients had non-concentric atlanto-occipital joints and/or soft tissue findings. CONCLUSION: Craniocervical measurements have poor accuracy for identifying craniocervical injuries in pediatric patients with incomplete craniocervical ligament disruption. Subjective findings of craniocervical injury are frequently present on CT in pediatric patients and can help increase sensitivity for identifying injury.

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OBJECTIVE: Our purpose was to assess the calibration of resident, fellow, and attending radiologists on a simple image classification task (presence or absence of an anterior cruciate ligament [ACL] tear based on interpretation of sagittal proton density, fat-saturated MR images) and to assess whether teaching residents could improve their calibration. METHODS: We created a test containing 30 randomized, sagittal, proton density, fat-saturated MR images of the ACL (15 normal, 15 torn). This test was administered in person to 20 trainees and 3 attendings at one medical center in one state. An online version of the test was given to 23 trainees and 14 attendings from 11 other medical centers in nine other states. Subjects were asked to give their confidence level (0%-100%) that each ACL was torn. RESULTS: Cross-sectional data were collected from 60 radiologists (mean time after medical school = 9.3 years, minimum = 1 year, maximum = 36 years). This demonstrated a statistically significant improvement in calibration as a function of increasing experience (P = .020). Longitudinal data were collected from 12 trainees at the start and end of their musculoskeletal radiology rotation, with an intervening review of the primary and secondary signs of ACL tear on MR. A statistically significant improvement in calibration was noted during the rotation (P = .028). CONCLUSIONS: Confidence calibration is a promising tool for quality improvement and radiologist self-assessment. Our study showed that calibration loss improves with experience in radiologists tested on a common and clinically important image classification task. We also demonstrated that calibration can be successfully taught to residents over a relatively short period (2-4 weeks).

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OBJECTIVE. The purpose of this study was to describe the epidemiology and imaging characteristics of cervical spine injuries in children with blunt trauma. MATERIALS AND METHODS. We conducted a retrospective review of the records of all patients 16 years old or younger with a diagnosis of cervical spine injury in the trauma registry of our level 1 trauma center between July 2006 and June 2018. RESULTS. Two hundred thirty-five patients were included in the study: 125 with subaxial cervical spine injuries, 87 with upper cervical spine injuries, and 23 with both subaxial and upper cervical spine injuries. The frequency of isolated upper cervical spine injuries was 73% in patients younger than 3 years old, 48% in patients 3-8 years old, and 29% in patients older than 8 years old. Seventy-one percent of occipital condyle fractures were avulsions, and 26% of dens fractures were avulsions. Type II dens fractures were found only in patients older than 8 years old. Type I and III dens fractures were almost exclusively in patients 8 years old or younger. Injuries classified as AOSpine types A, B, and C comprised 65.6%, 17.2%, and 17.2% of subaxial injuries, respectively. Despite similar mechanism of injury distribution across age groups, the frequency of AOSpine type A injuries in patients older than 8 years old (70.6%) was significantly higher compared with patients younger than 3 years old (40.0%) and those who were 3-8 years old (45.0%). The frequency of AOSpine type B injuries in patients younger than 3 years old (40.0%) was slightly higher than patients who were 3-8 years old (30.0%) and almost three times higher than in patients older than 8 years old (13.8%). CONCLUSION. Pediatric patients have high rates of upper cervical spine injuries, which tend to be distraction injuries that are frequently associated with avulsion fractures. Injury patterns in pediatric patients vary significantly by age, with patients younger than 3 years old being particularly prone to distraction type injuries.

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Calcific tendinopathy of the rotator cuff is a common pathology that often presents with clinical symptoms simulating a rotator cuff tear. The reported incidence of rotator cuff tear in the setting of calcific tendinopathy varies widely; however, the reported incidence of full-thickness rotator cuff tear on imaging in calcific tendinopathy is consistently low (<5%). In patients with symptomatic calcific tendinopathy, initial conservative management followed by minimally invasive treatments should be employed prior to performing shoulder magnetic resonance imaging to assess for a rotator cuff tear. A shoulder magnetic resonance imaging may be performed for preoperative planning prior to surgical removal of calcium deposits, but even in this patient population, the incidence of full-thickness rotator cuff tear is low.

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PURPOSE: To evaluate thoracolumbar spine injury patterns, demographics, and clinical characteristics in pediatric patients following all-terrain vehicle-related trauma. METHODS: A retrospective review of patients 0-17 years old admitted to a level I trauma center following an ATV-related incident from 2004 to 2013 was performed. Thoracolumbar spine injury patterns, accident mechanism, driver/passenger status, and demographic and clinical data were compared between patients with and without a spine injury. RESULTS: Of 456 pediatric patients involved in ATV-related trauma, 36 sustained one or more thoracolumbar spine injuries (7.9%). These patients tended to be older, taller, heavier, and had a higher BMI. ATV rollover was the major statistically significant mechanism of injury to cause spine fractures (61%). Patients with spine injuries had twice the hospital length of stay compared with those without (4 days vs. 2 days, P = 0.003). Nonstructural spine injuries (A0) were the most common type of injury (49.1%), followed by wedge-compression fractures (A1) (41.1%). In patients with a thoracolumbar spine injury, there was a mean of 3.11 spine injuries per child. Four (10%) patients with thoracolumbar spine fractures also sustained a cervical spine fracture. CONCLUSION: Once a thoracolumbar spine injury has been detected in a patient, the entire spinal column should be scrutinized because there is a high likelihood for additional injuries throughout the spine. Younger pediatric patients (≤ 8 years old) exhibit a spine fracture pattern distinct from that of older children who have a mature osseous-ligamentous complex.

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OBJECTIVE. The purpose of this article is to summarize the nomenclature of nonneoplastic conditions affecting subchondral bone through a review of the medical literature and expert opinion of the Society of Skeletal Radiology Subchondral Bone Nomenclature Committee. CONCLUSION. This consensus statement summarizes current understanding of the pathophysiologic characteristics and imaging findings of subchondral nonneoplastic bone lesions and proposes nomenclature to improve effective communication across clinical specialties and help avoid diagnostic errors that could affect patient care.

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Malignant intraosseous peripheral nerve sheath tumor is a very rare malignancy most commonly seen in patients with neurofibromatosis type 1. This tumor almost exclusively occurs in the maxillofacial region, with manifestation of this tumor in other regions of the skeleton infrequently reported. We describe a 23-year-old female with previously undiagnosed neurofibromatosis type 1 presenting with lower extremity weakness, paresthesias, and bowel/bladder symptoms. The patient had an aneurysmal lytic bone lesion centered in the upper sacrum with invasion of the L5 vertebral body. On MRI, the lesion was homogeneously isointense to muscle on T1, heterogeneously hyperintense to muscle on T2, and demonstrated homogeneously avid contrast enhancement. Multiple additional small lesions with similar imaging characteristics were identified in the paraspinal soft tissues. Low grade malignant peripheral nerve sheath tumor of the sacrum was diagnosed on biopsy. The patient was treated with sacral resection and radiation therapy for local disease control.

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Injuries to the cervical and thoracolumbar spine are commonly encountered in trauma patients presenting for treatment. Cervical spine injuries occur in 3% to 4% and thoracolumbar fractures in 4% to 7% of blunt trauma patients presenting to the emergency department. Clear, validated criteria exist for screening the cervical spine in blunt trauma. Screening criteria for cervical vascular injury and thoracolumbar spine injury have less validation and widespread acceptance compared with cervical spine screening. No validated criteria exist for screening of neurologic injuries in the setting of spine trauma. CT is preferred to radiographs for initial assessment of spine trauma. CT angiography and MR angiography are both acceptable in assessment for cervical vascular injury. MRI is preferred to CT myelography for assessing neurologic injury in the setting of spine trauma. MRI is usually appropriate when there is concern for ligament injury or in screening obtunded patients for cervical spine instability. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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Shoulder girdle trauma is one of the most common injuries encountered in emergency centers. These injuries can be easily overlooked due to the complex osteology of the shoulder. Although radiographs are usually sufficient for assessing traumatic shoulder injuries, cross-sectional imaging is sometimes indicated to assess portions of the shoulder not well visualized by radiographs. In this article, the authors review the spectrum of shoulder girdle injuries: sternoclavicular dislocations, clavicle fractures, acromioclavicular separations, shoulder dislocations, scapula fractures, and scapulothoracic dissociation. They also discuss the presentation, imaging evaluation, and classification of these injuries with emphasis on pitfalls in imaging diagnosis and indications for computed tomography/magnetic resonance.

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PURPOSE: To identify morphologic features of isolated cervical spine facet fractures that can reliably differentiate AOSpine F1 and F2 injuries. MATERIALS AND METHODS: Retrospective review of cervical spine CTs on all patients who sustained isolated cervical fractures of the facets presenting to our level 1 trauma center from August 2012 through December 2015. CTs were reviewed for facet fracture characteristics and AOSpine facet fracture classification. Association between facet fracture characteristics and AOSpine classification was assessed through multivariable logistic regression models. RESULTS: Fifty-six patients with cervical spine fractures isolated to the facets were included in the study. The mean age was 36 (range 9-90) years with 55.4% (n = 31) males. A significant correlation was found between subtype F1 and subtype F2 in laterality (left- or right-sided) (p = 0.004), interfacetal fracture involvement (p < 0.0001), transverse process involvement (p < 0.001), displacement of fracture fragment (p < 0.001), comminution of fracture (p < 0.0001), and vertebral arch disruption (p = 0.001). After multivariable analysis, left side laterality (p = 0.03), transverse process involvement (p = 0.01), and fracture comminution (p = 0.003) were associated with F2 fractures. CONCLUSION: Facet fractures with transverse process involvement or comminution have a higher probability of being an F2 fracture. These characteristics may be helpful when categorizing facet fractures using the AOSpine classification.

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PURPOSE: To evaluate chest injury patterns in pediatric patients involved in all-terrain vehicle (ATV) accidents. METHODS: Retrospective review of patients 0-18 years old admitted to a level I trauma institute following an ATV-related incident from 2004 to 2013 was performed. Chest injury type, accident mechanism, driver/passenger status, and demographic and clinical data were compared between patients with and without chest injury. RESULTS: Chest injury was present in 102 (22%) of total 455 patients. The most common chest injuries were pulmonary contusion (61%), pneumothorax (45%), and rib fracture (34%). There were no cardiac, esophageal, or tracheobronchial injuries. Pulmonary lacerations, hemothoraces, and scapular fractures were predominantly not detected on radiography and recognized on CT only (86-92%). Patients with chest injury had longer median hospital stays (3 days vs 2 days, p = 0.0054). There was no significant difference in admission to intensive care after controlling for injury severity scores in patients with chest injury compared to those without (17 vs 9). Eight patients with chest injury died (8%) compared to 2 patients without chest injury (0.6%) (p = 0.0002). CONCLUSIONS: Chest injuries are common in children following ATV accidents and may be a marker of more severe trauma. Increased public awareness of these potentially devastating injuries and continuing safety efforts are needed.

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Advances in oncologic treatment have improved survival rates, allowing late effects of radiotherapy to become more prevalent. Our patient, an 82-year-old woman with a remote history of right thigh basal cell carcinoma treated with resection and radiation therapy 18 years prior, presented with severe right thigh pain and inability to bear weight as she had suffered a femur fracture after a fall from standing. Initial imaging was suspicious for pathologic fracture secondary to malignancy due to imaging findings and because radiation-induced fractures have rarely been reported beyond 44 months from treatment. However, upon further imaging, evidence pointed to radiation-induced osteonecrosis as the mechanism for her insufficiency fracture. This case highlights the permanent deleterious effects of radiation therapy on bone, and the prudence of considering radiation-induced osteonecrosis as a mechanism of injury in low-energy trauma even long after radiation therapy. In addition, the case serves to review the natural history of irradiated bone injury and pertinent imaging findings.