Hilary Umans

This history page is dedicated to the history of the International Skeletal Society that just celebrated its 50th anniversary. As a society focused on the science and art of radiology of the skeleton, it is unique in its inclusion of both musculoskeletal radiologists and allied physicians with an interest in skeletal disease and disorders.

Purpose To identify correlated signs on non-enhanced MRI that might improve diagnostic detection of plantar plate (PP) tear. Materials and methods We performed an IRB-approved, HIPAA-compliant retrospective analysis of 100 non-contrast MRI (50 PP tear, 50 controls). All were anonymized, randomized, and reviewed; 20 were duplicated to assess consistency. One musculoskeletal radiologist evaluated qualitative variables. A trained non-physician performed measurements. Consistency and concordance were assessed. Pearson’s Chi-square test was used to test the correlation between qualitative findings and PP tear status. Correlation between measurements and PP status was assessed using t tests and Wilcoxon’s rank-sum test (p values < 0.05 considered significant). Classification and regression trees were utilized to identify attributes that, taken together, would consistently distinguish PP tear from controls. Results Quantitative measurements were highly reproducible (concordance 0.88–0.99). Elevated 2nd MT protrusion, lesser MT supination and rotational divergence of >45° between the 1st–2nd MT axis correlated with PP tear. Pericapsular soft tissue thickening correlated most strongly with PP tear, correctly classifying 95 % of cases and controls. Excluding pericapsular soft tissue thickening, sequential assessment of 2nd toe enthesitis, 2nd flexor tendon subluxation, and splaying of the second and third toes accurately classified PP status in 92 %. Conclusions Pericapsular soft tissue thickening most strongly correlated with PP tear. For cases in which it might be difficult to distinguish pericapsular fibrosis from neuroma, sequential assessment of 2nd toe enthesitis, flexor tendon subluxation and splaying of the 2nd and 3rd toe is most helpful for optimizing accurate diagnosis of PP tear.

Although the foot gets first billing in multiple articles and monographs focusing on foot and ankle imaging, the foot typically receives short shrift. Forefoot imaging has been a main focus of my research and clinical practice over the years. Initially, I sought to answer questions that were barely discussed in the literature. Even now, it seems that broad understanding and familiarity with midfoot and forefoot imaging lags behind the ankle, and that must change. We, most of us, walk upright, and, if we're lucky, we run and dance and wear stylish shoes. Midfoot and forefoot pain is a common clinical problem; therefore, we need to be expert foot imagers. It seems that referring clinicians have finally become at least as interested in the forefoot as I am. This is largely due to surgical innovations that now permit direct plantar plate repair via a dorsal incision. The forefoot has long been the “sole” purview of podiatrists but has more recently attracted the interest of orthopedic foot surgeons, particularly with regard to treatment of plantar plate tear. In an effort to make this issue clinically relevant, two of the articles were written in collaboration with renowned orthopedic foot surgeons from Brazil and Spain. I am impressed by the quality of the contributions from superb musculoskeletal radiologists around the world. Many of these authors are already familiar to you, and others will undoubtedly become familiar over the coming years. It is my hope that this issue will be of value for imagers and foot surgeons alike.

To identify the variety of second and third intermetatarsal space (IS) lesions that may coexist with and without adjacent metatarsophalangeal joint (MTP) plantar plate (PP) tears. One hundred forefoot MRIs in 96 patients with metatarsalgia obtained between 30 September 2011 and 21 July 2012 using 1.5- or 3-T MRI were retrospectively reviewed in consensus by two MSK radiologists and one podiatrist (DPM). MRI was evaluated for second and third MTP PP tear and the presence/nature of second and third IS lesions. Second and third IS neuromas were measured in transverse (trans) dimension. A total of 40 PP tears were identified: 36 at the second and 4 at the third MTP. Second MTP PP tear was identified in 33 % of females and 40.5 % of males. In the 63 female feet there were 21 second MTP PP tears, all of which also had second IS lesions: pericapsular fibrosis (16), bursitis (4), and ganglion (1). In the 37 male feet there were 15 second MTP PP tears, 14 of which had second IS lesions: pericapsular fibrosis (8), bursitis (5), and ganglion (1). There was no definite second IS neuroma adjacent to any second MTP PP tear. In females without PP tear, there were 24 second (3 mm trans average) and 43 third IS neuromas (4.1 mm trans average). In males without PP tear, there were 9 second (3.4 mm trans average) and 16 third IS neuromas (4.1 mm trans average). MTP PP tears occurred in 40 % of our cases, 90 % of which occurred at the second MTP. Almost all coexisted with non-neuromatous second IS lesions.

We present a case of sea urchin spine arthritis (SUSA) in a 33-year-old woman who sustained penetrating trauma to the interphalangeal (IP) joint of the hallux while snorkeling in Japan. Serial radiographs and MRI were obtained over a period from 7 weeks to 10 months following injury. At 7 weeks radiographs revealed periarticular osteopenia and subtle marginal erosion, similar to the appearance of tuberculous arthritis. Over the ensuing months, radiographs and MRI documented progressive marginal and periarticular erosions with synovitis, despite preservation of cartilage space and restoration of bone mineral density. Delayed radiographs and imaging features mimic gouty arthropathy. Only the history points to the proper diagnosis, which was confirmed by histopathology, demonstrating necrobiotic granuloma with central fibrinoid necrosis following synovectomy and arthrodesis. The majority of previous case reports affected the hand, with few cases in the feet. In all, radiographic illustrations were limited and demonstrated only minimal osteolysis and periosteal reaction. No other report included MRI or serial radiographs over a long period to illustrate the natural progression of the disease.

Objective To describe the clinical and MR imaging features of a unique strain at the iliac tubercle enthesis. While this strain appeared to correspond to the iliotibial band (IT band) enthesis, the literature regarding the IT band origin was discrepant. As such, our second goal was to prove that the IT band originated at the iliac tubercle, through cadaveric dissection. Materials and methods Three musculoskeletal radiologists prospectively reviewed 67 consecutive bony pelvis MRI studies from October 2006 through September 2008 using either 3, 1.5, or 0.3 T units. Seven cases demonstrating strain at the iliac tubercle enthesis were identified and reviewed by consensus. History and patient demographics were reviewed. Cadaveric dissection was performed to delineate the anatomy of the proximal IT band. Results Seven out of 67 individuals, all women, were identified with strain at the level of the iliac tubercle (prevalence 10%). Four of seven were athletes, three were overweight. Patients presented with pain and tenderness at the iliac tubercle. Anatomic dissection confirmed that iliotibial band originates along the margin of the iliac crest with dominant fibers condensing on the iliac tubercle. Conclusion Proximal IT band strain represents a unique injury that should be considered in patients who are female athletes or older overweight women who present with pain and tenderness at the iliac tubercle. Imaging of this entity must include the iliac tubercle, which is often excluded in standard hip MRI.

OBJECTIVE. The purpose of this article was to report our experience using ultrasound to assess digital nerve integrity after penetrating hand trauma with sensory deficit. Ultrasound was performed in the long axis on 22 digital nerves in 11 patients using a 12–14-MHz linear array hockey stick transducer.CONCLUSION. Of 22 volar digital nerves evaluated by sonography, six were transected. All imaging findings were confirmed surgically. High-frequency ultrasound permits accurate imaging of intact and transected volar digital nerves.