Address reprint requests to: J.S. Apple, M.D., Box3808, Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA diated to the left thigh and back. At that time she consulted a surgeon who noted a "s tony" hard lesion in the left buttock with surrounding erythemia and induration. The only positive laboratory finding was an LDH of 520 units. Four months prior to admission new lesions developed in the right buttock and these continued to enlarge, including the development of a new lesion on the left a r m a t the time of admission. The patient reported increasing fatigue, decreased appetite and a weight loss of 15 pounds over the three-months period prior to admission. She had passed renal calculi of unknown composition on four occasions, most recently three years prior to admission. The family history was negative except that the patient's spouse, an insulin-dependent diabetic, had died unexpectedly two years previously, after which the patient had lived alone. The pertinent physical findings were limited to the skin. The cutaneous lesions consisted of indurated areas of skin localized to the lateral surfaces of the upper arms extending over the regions of the thighs, both buttocks and deltoid. The induration had an irregular surface that was firm in most areas and "stone-like" in other regions. Blood profile and chemistries were normal except for an LDH of 584 units and a SGOT of 68 units. Xeroradiographs of the hips demonstrated punctate opacities (suggesting calcification) in the soft tissues lateral to both hips with nodular deformities of the subcutaneous tissues (Fig. 1 A). Xeroradiography of the left arm showed a single calcific-like opacity with marked distortion of the subcutaneous tissue, including fat planes, by fibrous strands (Fig. 1 B). The underlying skeletal structures were normal. A biopsy of the left buttock was performed.

A retrospective analysis of pediatric admissions over 10 years revealed 29 patients with cervical spine injuries. Eleven patients were below 12 years of age, and 10 of these had injuries involving C1, C2, or the occipitoatlantal articulation. Eighteen patients were between 12 and 16 years of age with injuries distributed throughout the cervical spine similar to injuries in the adult population. Our results suggest that teenagers with suspected cervical injuries are best evaluated by an adult radiographic series including trauma oblique views. In younger patients, careful evaluation of occipitoatlantoaxial alignment and the prevertebral soft tissues is required for diagnosis and selection of additional imaging evaluation.

Pluridirectional tomography in coronal and sagittal planes has been used to identify occult carpal pathology in 23 patients with chronic wrist pain following recent or remote trauma. The tomographic studies have detected or further defined the carpal pathology in 22 of the 23 patients studied adding useful information concerning their clinical management.

Osteoarthritis (OA) of the sternoclavicular (SC) joint has been extensively characterized in the pathology literature, but the radiographic appearance of this entity has received comparatively little attention. To define the radiographic patterns of OA at this joint, we used high resolution PA radiographs (industrial grade film) to examine 55 SC joints obtained by block resection at autopsy. Ten of these also were selected for coronal complex motion tomography. Fifty cases were histologically correlated. Radiographic and pathologic material was evaluated by four criteria characteristic of OA: joint-space narrowing, osteophytes, sclerosis, and cysts. Each criterion was independently assessed for severity and distribution. Moderate or severe radiographic changes of OA were uncommon in specimens younger than age 40, but present in 53% older than age 60. Changes were typically bilateral, although a mild degree of asymmetry was common. OA was most severe along the inferior portion of the clavicular head, which comprises its articulating margin with the sternum. Complex motion tomography was generally more accurate than plain radiography for assessing OA in the ten specimens in which comparison was performed.

Isolated enlargement of the cervical intervertebral foramen is frequently associated with dumbbell neurogenic tumors. We present an unusual case of isolated enlargement of a cervical intervertebral foramen in a 77-year-old male with an aggressive papillary thyroid carcinoma. To our knowledge, this represents the first case describing a thyroid process as a cause of foraminal enlargement.

Digital subtraction techniques are easily adapted to the evaluation of loosening in total hip prostheses, allowing real time review of injection dynamics and data manipulation after the study. We have successfully used both standard radiographic and digital imaging techniques in the evaluation of 15 prosthetic hip joints. The digital results are comparable to and often better than those of standard radiographic techniques for the evaluation of loosening in total hip prostheses.

Address reprint requests to." J.S. Apple, M.D., Box3808, Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA diated to the left thigh and back. At that time she consulted a surgeon who noted a ~176 stony" hard lesion in the left buttock with surrounding erythemia and induration. The only positive laboratory finding was an LDH of 520 units. Four months prior to admission new lesions developed in the right buttock and these continued to enlarge, including the development of a new lesion on the left arm at the time of admission. The patient reported increasing fatigue, decreased appetite and a weight loss of 15 pounds over the three-months period prior to admission. She had passed renal calculi of unknown composition on four occasions, most recently three years prior to admission. The family history was negative except that the patient's spouse, an insulin-dependent diabetic, had died unexpectedly two years previously, after which the patient had lived alone. The pertinent physical findings were limited to the skin. The cutaneous lesions consisted of indurated areas of skin localized to the lateral surfaces of the upper arms extending over the regions of the thighs, both buttocks and deltoid. The induration had an irregular surface that was firm in most areas and "stone-like" in other regions. Blood profile and chemistries were normal except for an LDH of 584 units and a SGOT of 68 units. Xeroradiographs of the hips demonstrated punctate opacities (suggesting calcification) in the soft tissues lateral to both hips with nodular deformities of the subcutaneous tissues (Fig. 1 A). Xeroradiography of the left arm showed a single calcific-like opacity with marked distortion of the subcutaneous tissue, including fat planes, by fibrous strands (Fig. 1 B). The underlying skeletal structures were normal. A biopsy of the left buttock was performed.

Computed tomography defines the anatomy and pathology of the talus, the calcaneus, and intervening joints better than conventional modalities. It enhances the understanding and diagnosis of the various musculoskeletal disorders affecting those structures. As a result, the clinical and surgical management is improved.

Forty patients were randomized in a double-blind study to compare the safety and diagnostic quality of Hexabrix vs. Renografin-60 without epinephrine in knee arthrography. Hexabrix is a monoacidic dimer of meglumine and sodium salts of ioxaglic acid with a lower osmolality than conventional contrast agents of similar concentration (32% iodine). Initial films were of equally high diagnostic quality for both groups, but delayed films at 20 and 30 min significantly favored Hexabrix for diagnostic quality. Hexabrix proved to be a safe and effective contrast agent for knee arthrography.

Three cases of bilateral pelvic avulsion fractures in adolescent sprinters are reviewed. An-acute avulsion fracture of the anterior superior iliac spine (ASIS) occurred during active running in three teenaged sprinters. Radiography confirmed a healed fracture of the contralateral ASIS. The clinical features and radiologic appearances are characteristic. The pathophysiology of this type of unique pediatric fracture is discussed. Conservative treatment is successful.

Martinez, S. M.D.; Khoury, Maroon B. M.D.; Harreison, John M.D.; Apple, Jerry S. M.D.; Munley, James M.D.

To clarify the role of standard chest radiography in prostatic adenocarcinoma, the pulmonary manifestations of 198 patients with Stage D disease were evaluated. All patients were treated with chemotherapeutic protocols allowing for adequate clinical and radiographic correlation. Retrospective interpretation of serial chest radiographs revealed that 35% of our patients had visible intrathoracic abnormalities; however, only 24% of the patients had abnormalities attributable to intrathoracic metastases. Twenty-two percent of patients had pleural effusions, 16% reticular opacities, 3.5% reticulonodular opacities, 8% isolated or discrete pulmonary nodules, and 4.5% adenopathy. Etiologies of these opacities included metastatic disease in 93.5% of those with adenopathy and nodular or reticulonodular opacities, but 39% of pleural effusions and 52% of reticular opacities were best attributed to concomitant processes. Four patients had intrathoracic metastases without bone metastases. Standard chest radiography is a valuable screening procedure that should be correlated with clinical data to differentiate metastases from concomitant processes.

Martinez, Salutario M.D.; Apple, Jerry S. M.D; Harrelson, John M. M.D; Polisson, Richard M.D; Drezner, Marc M.D.

Painful os styloideum: bone scintigraphy in carpe bossu diseaseJS Apple, S Martinez and JA NunleyAudio Available | Share

Chronic debilitating diseases may predispose to various joint infections, but early diagnosis of septic arthritis of the hip may be difficult. Klebsiella pneumoniae is an organism uncommonly found in joint infections. We have reviewed the literature on Klebsiella pneumoniae septic arthritis and described a case of a diabetic patient who had severe destruction of the hip joint over a six-month interval due to Klebsiella pneumoniae infection.

Apple, Jerry S. M.D.; Roberts, L. Jr. M.D.; Gamba, J. M.D.; Martinez, S. M.D.; Khoury, M. M.D., and; Ford, K. M.D. Author Information

Five cases of axial skeletal osteoid osteomas were viewed with particular attention to the role of computed tomography (CT) as a key diagnostic tool in the evaluation of osteoid osteoma. The complex anatomy of the axial skeleton can make the diagnosis of osteoid osteoma extremely difficult on routine films or tomograms, and the lesion often is well delineated only on CT scans. As complete surgical excision of this benign bony tumor is curative, precise anatomic localization is essential to the surgeon. The unique cross-sectional display of CT of the axial skeleton provides the surgeon with the exact location and extent of the lesion, which may allow a more limited surgical resection of the involved bone by defining the optimal surgical approach or procedure. Conventional radiographs were normal in all patients. Bone scans were positive when obtained and were useful in localizing the lesion and directing CT to the appropriate level. In all five cases CT was of proven value in accurately demonstrating the location, nidus, and other characteristic diagnostic radiographic features of osteoid osteoma.