Write short notes on the following:

Blow-out fracture Ossifying fibroma Microcolon Salter-Harris fracture Technique of radioisotope scanning of pulmonary embolism

BLOW-OUT FRACTURE
Introduction Aetiology Incidence Types Clinical features Imaging modalities Complications

INTRODUCTION

Blow-out fracture is defined as the fracture of the orbital wall with increase in intraorbital pressure and soft tissue herniation. It is usually the result of a direct blow to the orbit. This results in a sudden increase in the intraorbital pressure which in turn causes decompression by fracture of one or more of the bounding walls of the orbit. Pure blowout fractures usually occurs in the weakest parts where the wall is thin i.e the floor, the medial wall or, occasionally, the roof.

The orbit is a four-sided pyramidal space formed by seven bones Lateral wall: zygoma, greater wing of sphenoid Superior wall (Roof): orbital plate of the frontal bone, lesser wing of the sphenoid Medial wall: ethmoid, lacrimal, maxilla and sphenoid bones. There is a paper-thin bone, lamina papyracea, between the orbit and the ethmoids Inferior wall (Floor): maxilla, zygoma, palatine

BONY ORBIT

AETIOLOGY
Direct orbital blunt injury e.g via fists, elbows Sports injury e.g via impact of squash ball, baseball, tennis ball etc., all of which have diameters greater than the orbital rim Motor vehicle accidents Facial trauma

INCIDENCE
The commonest group of patients are young men. This is because blow-out fracture is usually due to trauma, often of sporting origin.

TYPES OF BLOW-OUT FRACTURE

Inferior blow-out fracture: It is the most common. There is prolapse of orbital fat ( inferior rectus muscle) into the maxillary sinus. In approximately 50% of cases, it is associated with fractures of the medial wall Medial blow-out fracture: It is the second most common type, occurring through the lamina papyracea. Orbital fat and the medial rectus muscle may prolapse into the ethmoid air cells. Superior blow-out fracture: Uncommon. Fractures may involve the frontal sinus and/or the anterior cranial fossa Lateral blow-out fracture: It is rare and associated with significant craniofacial injuries

CLINICAL FEATURES

Pain Periorbital swelling Temporary or permanent loss of vision Limitation of range of ocular motion Subconjunctival haemorrhage Facial asymmetry Diplopia due to extra-ocular muscle entrapment

IMAGING MODALITIES
Plain radiography CT scan MRI Ultrasound Angiography

PLAIN RADIOGRAPHY

Views include OM, OF, lateral Occipitomental (OM) view is the most suitable to assess inferior orbital wall fractures. This may reveal discontinuity within the orbital floor, air-fluid level or soft tissue density within the maxillary sinus, a polypoid mass hanging from the floor into the maxillary antrum (tear-drop sign). This polypoid mass consists of herniated orbital contents, periorbital fat and inferior rectus muscle. Occipitofrontal (OF) view better assesses medial orbital wall fracture. Penetration of air from the ethmoidal sinus is seen as lucency in the orbit (Orbital emphysema). Fluid may be also seen in the ethmoidal sinus

Plain skull radiograph (OM view) showing a mass projecting from the left orbital floor into the left maxillary sinus

CT SCAN

Due to its good bony resolution and multi-slice properties, CT gives better localisation of fracture site by clearly defining bone fragments, air and foreign body. A hypodense discontinuity is seen within the hyperdense orbital wall. Associated findings include: presence of intra-orbital haemorrhage, globe injury/rupture, extraocular muscle entrapment and prolapse of orbital fat CT may also reveal bleeding into the sinus, which, depending on the duration, can be hyperdense (acute), isodense (subacute) or hypodense (chronic)

Coronal cranial CT image showing fracture of the right inferior orbital wall with herniation of orbital contents into the right maxillary sinus

Coronal cranial CT image showing fractures of the left inferior and medial orbital walls

Cranial CT image (saggital reformat) demonstrating fracture of the left inferior orbital wall with associated inferior rectus muscle entrapment

MRI

MRI gives excellent soft tissue resolution and multiplanar images of the orbits. Prolapsed orbital fat appears hyperintense on both T1 and T2 sequences The signal intensity of any associated haemorrhage varies depending on the duration of the bleed

T1-weighted coronal cranial MR image showing inferior herniation of the right orbital fat

ULTRASOUND

This employs the use of a high-frequency ultrasonic transducer to assess for possible complications of orbital contents Vitreous haemorrhage is seen as internal echoes within the posterior segment. Retinal or choroid detachment is seen as a V-shaped echogenicity in the posterior part of the eye . A foreign body within the orbit is echogenic with/without posterior acoustic shadow

ANGIOGRAPHY

This includes conventional angiography, CTA or MRA Useful in the assessment of the ophthalmic artery

COMPLICATIONS
Subluxation/dislocation/rupture of the lens Vitreous haemorrhage Retinal or choroid detachment

OSSIFYING FIBROMA
Introduction Incidence Clinical features Imaging modalities Radiological features Complications Differentials

INTRODUCTION

Ossifying fibroma is a benign slow-growing central bone tumour composed of bone that develops within fibrous connective tissue. It is also known as Osteofibrous Dysplasia (OFD) or Jaffe-Campanacci Syndrome. The pathology comprises maturing cellular fibrous spindle cells with osteoblastic activity producing many calcific cartilaginous and bone densities

INCIDENCE

It occurs commonly in the 2nd to 4th decade of life M<F Common locations include: Lower extremity: Tibia: seen in 90% of cases. There is predilection for the anterior tibial cortex Femur: Usually occurs in the diaphysis Jaw: maxilla and mandible. Also known as cemento-ossifying fibromas Frontal bone, ethmoid bone etc

CLINICAL FEATURES
Pain (though usually painless) Swelling Facial asymmetry due to bone expansion Tooth displacement

IMAGING MODALITIES
Plain radiography CT scan MRI Radionuclide imaging

PLAIN RADIOGRAPHY
It is seen as a well circumscribed lesion surrounded by a thin line of lucency (fibrous capsule), which is in turn surrounded by thin sclerotic rim of reactive bone (osteoblastic rimming). May present as eccentric groundglass lesion, resembling fibrous dysplasia There is moderate expansion of intact cortex

CT SCAN

CT demonstrates a well circumscribed homogeneous lesion with evidence of intracortical hypodensity and characteristic hyperdense band (osteoblastic rimming)

Axial CT of the lower jaw (bone window) showing a circular partially calcified lesion within the mandible. There are internal ground-glass calcifications

MRI

The lesion is hypointense on T1 and (with typical contrast enhancement) and iso- to hyperintense on T2

RADIONUCLIDE IMAGING

It shows intense focal uptake on 99mTc bone scan.

COMPLICATIONS

Pathological fracture Limb bowing Recurrence

TREATMENT/PROGNOSIS

Ossifying fibroma tends to regress over time. For locally aggressive lesions, surgical resection is often curative

DIFFERENTIALS

Fibrous dysplasia: Has no osteoblastic rimming Adamantinoma: May share a common origin with ossifying fibroma. It is distinguished from ossifying fibroma by presence of soft tissue extension, intramedullary extension and periosteal reaction. Osteoid osteoma: Consists of 3 concentric parts nidus, fibrovascular rim and surrounding reactive sclerosis

MICROCOLON
Definition Aetiology Clinical presentation Imaging modalities Radiological features

DEFINITION
Microcolon is a radiological finding of smallcalibre unused colon, seen in the neonate on radiographic contrast enema It signifies intestinal obstruction above the colon and it is probably caused in utero by lack of appropriate distension of the colon with intramural content There are no absolute standards for the measurement of this condition.

AETIOLOGY
Mnemonic: MI MCA Meconium ileus/meconium peritonitis Ileal/jejunal atresia Megacystis-microcolon-hypoperistalsis syndrome Colonic atresia Aganglionosis (Hirschsprungs disease)

CLINICAL PRESENTATION
Abdominal distension Bilous vomiting Failure to pass meconium within 48hours

IMAGING MODALITIES
Plain radiography Contrast enema Ultrasound CT scan MCUG

MECONIUM ILEUS

This is the obstruction of the small bowel in the terminal ileum from impacted meconium It manifests within 48 hours of birth. Meconium is normally evacuated within first 6 hours Majority of infants with meconium ileus prove to have cystic fibrosis. Approximately 20% of infants with cystic fibrosis present with meconium ileus at birth. It may also be seen with pancreatic atresia or stenosis of the pancreatic duct

MECONIUM ILEUS (CONTD)

Plain Radiography: Non-specific. May show dilated small bowel loops without airfluid levels (fluid not present) Bubbly/frothy appearance of the distended intestinal loops Soap bubble appearance in right lower quadrant due to admixture of gas with meconium Contrast Enema Multiple round/oval filling defects in distal ileum & colon Functional microcolon (unused colon in antenatal obstruction) Obstetric ultrasound Echogenic bowel which can be dilated and thick-walled Polyhydramnios Fetal ascites Intra-abdominal cysts

MECONIUM ILEUS CONTD)

MECONIUM PERITONITIS

This refers to sterile chemical peritonitis secondary to perforation of bowel proximal to complete obstruction that seals in utero due to inflammatory response Causes as for microcolon Plain radiography: intra-abdominal calcifications Contrast enema: separation of bowel loops by fluid; microcolon Ultrasound: highly echogenic material throughout the abdomen in between bowel loops (snowstorm appearance) Obstetric ultrasound: as for meconium ileus

MECONIUM PERITONITIS (CONTD)

JEJUNAL/ILEAL ATRESIA

This is a congenital anomaly characterized by closure of the jejunum or ileum. The aetiology is thought to be from an intrauterine ischaemic injury to the developing gut May be associated with malrotation, volvulus, gastroschisis, omphalocele Plain radiography: Triple bubble appearance (double bubble of duodenal atresia + third bubble due to air in the proximal jejunum). Multiple dilated small bowel loops proximal to the atresia Contrast enema: Typically shows microcolon Obstetric ultrasound: Dilated proximal bowel loops, often > 7mm

JEJUNAL/ILEAL ATRESIA (CONTD)

COLONIC ATRESIA
Less common than jejunal/ileal atresia Plain radiography: massive dilatation of colon proximal to obstruction. Mottled pattern of gas + feces proximal to point of atresia Contrast enema: Functional microcolon. There may be obstruction to retrograde flow of contrast Ultrasound: dilated echogenic distal small bowel + proximal colon (from retained meconium)

COLONIC ATRESIA (CONTD)

MEGACYSTIS-MICROCOLONHYPOPERISTALSIS SYNDROME

Also known as Berdon syndrome. M:F is 1:7 This is a functional obstruction of bladder + colon characterized by enlarged urinary bladder, small colon and markedly enlarged hydronephrotic kidneys with little remaining parenchyma The prognosis is lethal in most cases Obstetric ultrasound: female sex; normal amount of amniotic fluid in spite of dilated bladder; bilateral megaloureters hydronephrosis Contrast enema: microcolon with narrow rectum + sigmoid; malrotation or foreshortening of small bowel MCUG: Distended unobstructed bladder with poor/absent muscular function

HIRSCHSPRUNGS DISEASE

This is caused by absence of parasympathetic ganglia in muscle & submucosal layers due to an arrest of craniocaudal migration of neuroblasts along the vagal trunks Microcolon is seen in less than one-quarter of patients with total colonic Hirschsprungs disease Plain radiography: multiple dilatation of bowel loops Contrast enema: rectosigmoid calibre ratio less than one, microcolon, delayed/disordered evacuation of contrast from the colon, bowel shortening

HIRSCHSPRUNGS DISEASE

SALTER-HARRIS FRACTURE
Introduction Aetiology Incidence Types Clinical features Imaging modalities Complications

INTRODUCTION

Salter-Harris fractures are fractures that involve the epiphyseal plate of a bone. The fractures are classified into different types by Robert Salter and Robert Harris in their article Injuries Involving the Epiphyseal Plate in 1963. The importance of this classification system is to accurately diagnose a fracture so that the correct method of treatment can be performed swiftly to decrease the chances of growth disturbances and angular growth deformities.

AETIOLOGY

Sports injuries (one-third of cases) Child abuse Injury from extreme cold (e.g frostbite) Neurological disorders that result in sensory deficit or muscular imbalance Metabolic diseases e.g CRF, hormone disorders etc

INCIDENCE

Peak age is 12years M:F = 2:1 Upper extremity > Lower extremity (typically the distal radius) Mechanism: 80% shearing force; 20% compression

ANATOMY

The epiphyseal growth plate (where cartilage develops into bone) has four stages: germinal/resting zone, proliferative zone, hypertrophy zone, ossification zone. Hypertrophy zone is weakest and therefore is damaged by shearing forces that extend from there into epiphysis or metaphysis during Salter Harris fractures. Major blood supply to growth plate and its germinal layer is from epiphysis. Damage to the blood supply causes healing problems for Salter Harris fractures

ANATOMY

TYPES

Salter-Harris Fractures are categorized by the location of the fracture in one or more of the physis (epiphyseal plate), epiphysis, and metaphysis.

TYPE I (Slipped physis)

There is slip of epiphysis due to shearing force separating epiphysis from physis. The surrounding bone is not involved. Line of cleavage is confined to the physis Seen in 6 8.5% of cases There is widening of the growth plate as well as displacement of the epiphyseal ossification centre Commonly seen in the phalanges and distal radius. Slipped capital femoral epiphysis is a type I SHF Prognosis is favourable, irrespective of the location It is treated by simple closed reduction and immobilization

TYPE I (CONTD)

Salter Harris type I of distal radius

SLIPPED CAPITAL FEMORAL EPIPHYSIS

TYPE II (Above physis)

Shearing force splits the epiphyseal plate. The line of fracture passes across the epiphyseal plate and extends through the metaphysis. This separates a triangular metaphyseal fragment known as Thurston Holland fragment (Corner sign) This type is the most common, seen in 73 75% of cases. Commonly seen in distal radius (33 50%), distal tibia & fibula, phalanges. It is treated by closed reduction and immobilization The prognosis is good and complications are uncommon. However, it may result in minimal shortening

TYPE II (CONTD)

Salter Harris type II of the distal radius. There is also a fracture of the distal ulna

TYPE III (Lower than physis)

This is an intraarticular fracture, often occurring after partial closure of physis The line of fracture is vertically/obliquely through the epiphysis and extending horizontally to periphery of physis. Seen in 6.5 8% of cases. Commonly seen in distal tibia, distal phalanx, rarely distal femur The prognosis is fair. This type damages the proliferative and resting zones of the growth plate with fracture extending to articular surface of the bone. Treatment often requires surgery.

TYPE III (CONTD)

Salter Harris type III of distal tibia

TYPE IV (Through physis)

This is also an intraarticular fracture. The line of fracture passes directly through the metaphysis, epiphyseal plate and through the epiphysis Seen in 10 12% of cases. Commonly seen in lateral condyle of humerus and distal tibia The prognosis is guarded. This type interferes with the germinal layer and can cause premature focal fusion of involved bone thereby causing limb shortening. Treatment requires surgery in order to properly realign the joint surface

TYPE IV (CONTD)

Salter Harris type IV of the distal tibia

TYPE V (Rammed physis)

This type is due to crush injury with injury to the vascular supply. Crush injury does not displace the growth plate but damages it by direct compression. Commonly found in distal femur, proximal tibia, distal tibia Seen in <1% of cases No immediate radiographic finding. Can often go unnoticed until cessation of growth occurs. Worst prognosis (growth impairment in 100%)

TYPE V (CONTD)

Salter Harris type V of right distal radius. There is a "sclerotic" band across the distal metaphysis of the right radius where the impaction has taken place, and a small area of bulging on the ulnar aspect of the distal radius

CLINICAL FEATURES

Joint pain Joint swelling Limited range of motion in joint Point tenderness over the growth plate

IMAGING MODALITIES

Plain radiography CT scan MRI Ultrasound

PLAIN RADIOGRAPHY

This is the sole imaging method required in the majority of epiphyseal injuries. AP and lateral views are usually required. Comparison study of contralateral limb is also done. The epiphyseal plate is originally radiolucent. So, its fractures are not directly evident on plain x-rays. Fractures through the bones appear as linear radiolucency (area of discontinuity) within the bony outlines

CT SCAN

CT with its multiplanar reconstruction is required to demonstrate improved fracture anatomy for potential surgical intervention The fracture appears as linear hypodense area within the hyperdense bony outline

MRI SCAN
The fracture appears as focal hyperintense linear area (line of cleavage) within a hypointense physis on T1 and T2 images

CT scan of the right knee (volume rendering images) showing Salter-Harris type 2 supracondylar fracture of the right femur

ULTRASOUND

It is useful as ancillary imaging modality in assessing joint effusion, ligamental rupture, vascular injury etc

COMPLICATIONS

Progressive angular deformity Limb length discrepancy from growth arrest Articular incongruity from disruption of articular surface Bone infarction in metaphysis/epiphysis

TECHNIQUE OF RADIOISOTOPE SCANNING OF PULMONARY EMBOLISM Definition Contraindications Radiopharmaceuticals Equipment Patient preparation Technique Aftercare Complications

DEFINITION
Radioisotope scanning of pulmonary embolism is otherwise known as ventilationperfusion scintigraphy It is a non-invasive technique for the assessment of the distribution of pulmonary blood flow and alveolar ventilation.

CONTRAINDICATIONS
Right-to-left shunt: due to the risk of cerebral emboli Severe pulmonary hypertension

NB: Both are relative contraindications to perfusion imaging. In either of these cases, the number of particles should be reduced towards the lower end of the diagnostic range.

RADIOPHARMACEUTICALS
Perfusion imaging
This method demonstrates the distribution of lung perfusion using a 99mTc (Technetium)-labelled albumin tracer in the form of small particles. Adult dose is about 40 000 - 200 000 particles The particles are of such a size (about 10 40m in diameter) that they will be trapped in the precapillary arterioles of the lung in their first passage after intravenous injection. The injected particles occlude less than 0.5% of the vascular bed. After trapping in the lung, the particles are removed by the reticuloendothelial system over several

RADIOPHARMACEUTICALS (CONTD)

Ventilation imaging 81mKr (Krypton) gas: Optimal imaging agent. It has a short T of 13s and gamma-energy of 190keV. Simultaneous dual isotope ventilation and perfusion imaging is possible because of different energy to 99mTc. However, it is expensive and not readily available. 99mTc-Technegas: Similar diagnostic efficacy to krypton. Simultaneous imaging not possible. It is expensive.

RADIOPHARMACEUTICALS (CONTD)

Ventilation imaging
99mTc-DTPA:

Cheap and readily available. Simultaneous imaging is not possible. Less suitable in patients with COPD or chronic asthma due to likelihood of clumping of aerosol particles 133Xe (Xenon) gas: It has a long T of 5.25days and a gamma energy of 81keV. Ventilation must precede perfusion study because low gamma-energy would be swamped by scatter from 99mTc. Its images are of poor quality.

EQUIPMENT

Gamma-camera Low-energy general purpose collimator Gas-dispensing system and breathing circuit for ventilation

PATIENT PREPARATION
For ventilation, familiarization with breathing equipment A current CXR is required to assist with interpretation.

TECHNIQUE

Perfusion scintigraphy This method demonstrates the distribution of lung perfusion using a 99mTc-labelled albumin tracer in the form of small particles. The tracer is given intravenously in the supine, semi-recumbent or sitting position The syringe is shaken to prevent particles settling. A slow IV injection is given directly into a vein over about 10s. The patient must remain in position for 2-3mins while the particles become fixed in the lungs Imaging may begin immediately, preferrably in the sitting position

TECHNIQUE (CONTD)

Ventilation Scintigraphy If 81mKr gas is used, simultaneous Q/V imaging can be performed either by dual isotope acquisition or swapping energy windows at each patient position. The patient is positioned to obtain identical views to the perfusion images and asked to breathe normally through the mouthpiece The air supply attached to the generator is turned on and imaging commenced.

TECHNIQUE (CONTD)

Ventilation Scintigraphy If 99mTc-DTPA is used, this imaging is performed before the perfusion study. 99mTc-DTPA is drawn into a 5ml syringe with 2ml air, then injected into the nebulizer and flushed through with air The patient is positioned sitting with their back to the camera The air supply is turned on to deliver a rate of 10L/min and a nose-clip is placed in the patient, who is asked to breathe normally through the mouthpiece After reaching a sufficient count rate, the air supply is turned off. The patient continues to breathe through the mouthpiece for a further 15s The nose-clip is removed and the patient is given a mouth wash, then imaging is commenced.

TECHNIQUE (CONTD)

The images taken include anterior, posterior, left and right posterior obliques. These are preferred to lateral views in order to avoid small defects in one lung being obscured by counts shining through from the opposite lung. Characteristically, pulmonary embolism results in severe reduction or total loss of perfusion to the areas of lung supplied by the affected arteries, while ventilation remains unchanged or shows only a minor reduction.

AFTERCARE

None

COMPLICATIONS
Worsening of right heart failure in patients with severe pulmonary hypertension Risk of systemic embolisation in patients with right-to-left cardiac shunt

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