Made by DATEXIS (Data Science and Text-based Information Systems) at Beuth University of Applied Sciences Berlin
Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
Funded by The Federal Ministry for Economic Affairs and Energy; Grant: 01MD19013D, Smart-MD Project, Digital Technologies
Laximetry is a reliable technique for diagnosing a torn anterior cruciate ligament.
X-ray images (normally during weightbearing) can be obtained to rule out other conditions or to see if the patient also has osteoarthritis. The menisci themselves cannot be visualised with plain radiographs. If the diagnosis is not clear from the history and examination, the menisci can be imaged with magnetic resonance imaging (an MRI scan). This technique has replaced previous arthrography, which involved injecting contrast medium into the joint space. In straightforward cases, knee arthroscopy allows quick diagnosis and simultaneous treatment. Recent clinical data shows that MRI and clinical testing are comparable in sensitivity and specificity when looking for a meniscal tear.
The diagnosis is usually initially made by a combination of physical exam and MRI of the shoulder, which can be done with or without the injection of intraarticular contrast. The presence of contrast allows for better evaluation of the glenoid labrum.
Magnetic resonance imaging (MRI) can be helpful in assessing for a ligamentous injury to the medial side of the knee. Milewski et al. has found that grade I to III classification can be seen on MRI. With a high-quality image (1.5 tesla or 3 tesla magnet) and no previous knowledge of the patient’s history, musculoskeletal radiologists were able to accurately diagnose medial knee injury 87% of the time. MRI can also show associated bone bruises on the lateral side of the knee, which one study shows, happen in almost half of medial knee injuries.
Knee MRIs should be avoided for knee pain without mechanical symptoms or effusion, and upon non-successful results from a functional rehabilitation program.
Anterior-posterior (AP) radiographs are useful for reliably assessing normal anatomical landmarks. Bilateral valgus stress AP images can show a difference in medial joint space gapping. It has been reported that an isolated grade III sMCL tear will show an increase in medial compartment gapping of 1.7 mm at 0° of knee flexion and 3.2 mm at 20° of knee flexion, compared to the contralateral knee. Additionally, a complete medial ligamentous disruption (sMCL, dMCL, and POL) will show increased gapping by 6.5 mm at 0° and 9.8 mm at 20° during valgus stress testing. Pellegrini-Stieda syndrome can also be seen on AP radiographs. This finding is due to calcification of the sMCL (heterotopic ossification) caused by the chronic tear of the ligament.
The MRI is perhaps the most used technique for diagnosing the state of the Anterior Cruciate Ligament but it not always the most reliable. In some cases the Anterior Cruciate Ligament can indeed not be seen because of the blood surrounding it.
Most countries have standard newborn exams that include a hip joint exam screening for early detection of hip dysplasia.
Sometimes during an exam a "click" or more precisely "clunk" in the hip may be detected (although not all clicks indicate hip dysplasia). When a hip click (also known as "clicky hips" in the UK) is detected, the child's hips are tracked with additional screenings to determine if developmental dysplasia of the hip is caused.
Two maneuvers commonly employed for diagnosis in neonatal exams are the Ortolani maneuver and the Barlow maneuver.
In order to do the Ortolani maneuver it is recommended that the examiner put the newborn baby in a position in which the contralateral hip is held still while the thigh of the hip being tested is abducted and gently pulled anteriorly. If a "clunk" is heard (the sound of the femoral head moving over the acetabulum), the joint is normal, but absence of the "clunk" sound indicates that the acetabulum is not fully developed. The next method that can be used is called the Barlow maneuver. It is done by adducting the hip while pushing the thigh posteriorly. If the hip goes out of the socket it means it is dislocated, and the newborn has a congenital hip dislocation. The baby is laid on its back for examination by separation of its legs. If a clicking sound can be heard, it indicates that the baby may have a dislocated hip. It is highly recommended that these maneuvers be done when the baby is not fussing, because the baby may inhibit hip movement.
The condition can be confirmed by ultrasound and X-ray. Ultrasound imaging yields better results defining the anatomy until the cartilage is ossified. When the infant is around 3 months old a clear roentgenographic image can be achieved. Unfortunately the time the joint gives a good x-ray image is also the point at which nonsurgical treatment methods cease to give good results. In x-ray imaging dislocation may be indicated if the Shenton's line (an arc drawn from the medial aspect of the femoral neck through the superior margin of the obturator foramen) does not result in a smooth arc. However, in infants this line can be unreliable as it depends on the rotation of the hip when the image is taken ()
Asymmetrical gluteal folds and an apparent limb-length inequality can further indicate unilateral hip dysplasia. Most vexingly, many newborn hips show a certain ligamentous laxity, on the other hand severely malformed joints can appear stable. That is one reason why follow-up exams and developmental monitoring are important. Frequency and methods of routine screenings in children is still in debate however physical examination of newborns followed by appropriate use of hip ultrasound is widely accepted.
The Harris hip score (developed by William H. Harris MD, an orthopedist from Massachusetts) is one way to evaluate hip function following surgery. Other scoring methods are based on patients' evaluation like e.g. the Oxford hip score, HOOS and WOMAC score. Children's Hospital Oakland Hip Evaluation Scale (CHOHES) is a modification of the Harris hip score that is currently being evaluated.
Hip dysplasia can develop in older age. Adolescents and adults with hip dysplasia may present with hip pain and in some cases hip labral tears. X-rays are used to confirm a diagnosis of hip dysplasia. CT scans and MRI scans are occasionally used too.
Imaging diagnosis conventionally begins with plain film radiography. Generally, AP radiographs of the shoulder with the arm in internal rotation offer the best yield while axillary views and AP radiographs with external rotation tend to obscure the defect. However, pain and tenderness in the injured joint make appropriate positioning difficult and in a recent study of plain film x-ray for Hill–Sachs lesions, the sensitivity was only about 20%. i.e. the finding was not visible on plain film x-ray about 80% of the time.
By contrast, studies have shown the value of ultrasonography in diagnosing Hill–Sachs lesions. In a population with recurrent dislocation using findings at surgery as the gold standard, a sensitivity of 96% was demonstrated. In a second study of patients with continuing shoulder instability after trauma, and using double contrast CT as a gold standard, a sensitivity of over 95% was demonstrated for ultrasound. It should be borne in mind that in both those studies, patients were having continuing problems after initial injury, and therefore the presence of a Hill–Sachs lesion was more likely. Nevertheless, ultrasonography, which is noninvasive and free from radiation, offers important advantages.
MRI has also been shown to be highly reliable for the diagnosis of Hill-Sachs (and Bankart) lesions. One study used challenging methodology. First of all, it applied to those patients with a single, or first time, dislocation. Such lesions were likely to be smaller and therefore more difficult to detect. Second, two radiologists, who were blinded to the surgical outcome, reviewed the MRI findings, while two orthopedic surgeons, who were blinded to the MRI findings, reviewed videotapes of the arthroscopic procedures. Coefficiency of agreement was then calculated for the MRI and arthroscopic findings and there was total agreement ( kappa = 1.0) for Hill-Sachs and Bankart lesions.
Patients can be observed standing and walking to determine patellar alignment. The Q-angle, lateral hypermobility, and J-sign are commonly used determined to determine patellar maltracking. The patellofemoral glide, tilt, and grind tests (Clarke's sign), when performed, can provide strong evidence for PFPS. Lastly, lateral instability can be assessed via the patellar apprehension test, which is deemed positive when there is pain or discomfort associated with lateral translation of the patella.
The diagnosis of patellofemoral pain syndrome is made by ruling out patellar tendinitis, prepatellar bursitis, plica syndrome, Sinding-Larsen and Johansson syndrome, and Osgood–Schlatter disease.
The decisions involved in the repair of the Hill–Sachs lesion are complex. First, it is not repaired simply because of its existence, but because of its association with continuing symptoms and instability. This may be of greatest importance in the under-25-year-old and in the athlete involved in throwing activities. The Hill-Sachs role in continuing symptoms, in turn, may be related to its size and large lesions, particularly if involving greater than 20% of the articular surface, may impinge on the glenoid fossa (engage), promoting further episodes of instability or even dislocation. Also, it is a fracture, and associated bony lesions or fractures may coexist in the glenoid, such as the so-called bony Bankart lesion. Consequently, its operative treatment may include some form of bony augmentation, such as the Latarjet or similar procedure. Finally, there is no guarantee that associated non-bony lesions, such as a Bankart lesion, SLAP tear, or biceps tendon injury, may not be present and require intervention.
Anterior-posterior (AP) X-rays of the pelvis, AP and lateral views of the femur (knee included) are ordered for diagnosis. The size of the head of the femur is then compared across both sides of the pelvis. The affected femoral head will appear larger if the dislocation is anterior, and smaller if posterior. A CT scan may also be ordered to clarify the fracture pattern.
Arthroscopic repair of Bankart injuries have high success rates, with studies showing that nearly one-third of patients require re-intervention for continued shoulder instability following repair. Options for repair include an arthroscopic technique or a more invasive open Latarjet procedure, with the open technique tending to have a lower incidence of recurrent dislocation, but also a reduced range of motion following surgery.
In all injuries to the tibial plateau radiographs (commonly called x-rays) are imperative. Computed tomography scans are not always necessary but are sometimes critical for evaluating degree of fracture and determining a treatment plan that would not be possible with plain radiographs. Magnetic Resonance images are the diagnositic modality of choice when meniscal, ligamentous and soft tissue injuries are suspected. CT angiography should be considered if there is alteration of the distal pulses or concern about arterial injury.
A grade III PCL injury with more than 10mm posterior translation when the posterior drawer examination is performed may be treated surgically. Patients that do not improve stability during physical therapy or develop an increase in pain will be recommended for surgery.
According to the posterior cruciate ligament injuries only account for 1.5 percent of all knee injuries (figure 2). If it is a single injury to the posterior cruciate ligament that requires surgery only accounted for 1.1 percent compared to all other cruciate surgeries but when there was multiple injuries to the knee the posterior cruciate ligament accounted for 1.2 percent of injuries.
High quality MRI images (1.5 T magnet or higher ) of the knee can be extremely useful to diagnose injuries to the posterolateral corner and other major structures of the knee. While the standard coronal, sagittal and axial films are useful, thin slice (2 mm ) coronal oblique images should also be obtained when looking for PLC injuries. Coronal oblique images should include the fibular head and styloid to allow for evaluation of the FCL and popliteus tendon.
Isolated and combined posterolateral knee injuries are difficult to accurately diagnose in patients presenting with acute knee injuries. The incidence of isolated posterolateral corner injuries has been reported to be between 13% and 28%. Most PLC injuries accompany an ACL or PCL tear, and can contribute to ACL or PCL reconstruction graft failure if not recognized and treated. A study by LaPrade "et al." in 2007 showed the incidence of posterolateral knee injuries in patients presenting with acute knee injuries and hemarthrosis (blood in the knee joint) was 9.1%.
Diagnosis of tendinitis and bursitis begins with a medical history and physical examination. X rays do not show tendons or the bursae but may be helpful in ruling out bony abnormalities or arthritis. The doctor may remove and test fluid from the inflamed area to rule out infection.
Ultrasound scans are frequently used to confirm a suspected tendinitis or bursitis as well as rule out a tear in the rotator cuff muscles.
Impingement syndrome may be confirmed when injection of a small amount of anesthetic (lidocaine hydrochloride) into the space under the acromion relieves pain.
An effective rehabilitation program reduces the chances of reinjury and of other knee-related problems such as patellofemoral pain syndrome and osteoarthritis. Rehabilitation focuses on maintaining strength and range of motion to reduce pain and maintain the health of the muscles and tissues around the knee joint.
A meniscal tear can be classified in various ways: by anatomic location, by proximity to blood supply, etc. Various tear patterns and configurations have been described. These include:
- Radial tears;
- Flap or parrot-beak tears;
- Peripheral, longitudinal tears;
- Bucket-handle tears;
- Horizontal cleavage tears; and
- Complex, degenerative tears.
These tears can then be further classified by their proximity to the meniscus blood supply, namely whether they are located in the “red-red,” “red-white,” or “white-white” zones.
The functional importance of these classifications, however, is to ultimately determine whether a meniscus is repairable. The repairability of a meniscus depends on a number of factors. These include:
- Age/strength
- Activity level
- Tear pattern
- Chronicity of the tear
- Associated injuries (anterior cruciate ligament injury)
- Healing potential
After an anterior shoulder dislocation, the risk of a future dislocation is about 20%. This risk is greater in males than females.
The best diagnosis for a SLAP tear is a clinical exam
followed by an MRI combined with a contrast agent
Some sources prefer "developmental dysplasia of the hip" (DDH) to "congenital dislocation of the hip" (CDH), finding the latter term insufficiently flexible in describing the diversity of potential complications.
The use of the word congenital can also imply that the condition already exists at birth. This terminology introduces challenges, because the joint in a newborn is formed from cartilage and is still malleable, making the onset difficult to ascertain.
The newer term DDH also encompasses occult dysplasia (e.g. an underdeveloped joint) without dislocation and a dislocation developing after the "newborn" phase.
The term is not used consistently. In pediatric/neonatal orthopedics it is used to describe unstable/dislocatable hips and poorly developed acetabula. For adults it describes hips showing abnormal femur head or acetabular x-rays.
Some sources prefer the term "hip dysplasia" over DDH, considering it to be "simpler and more accurate", partly because of the redundancy created by the use of the terms developmental and dysplasia. Types of DDH include subluxation, dysplasia, and dislocation. The main types are the result of either laxity of the supporting capsule or an abnormal acetabulum.
Diagnosis is made on plain radiograph of the foot, although the extent of injury is often underestimated.
Treatment comprises early reduction of the dislocation, and frequently involves open reduction internal fixation to restore and stabilise the talonavicular joint. Open reduction and fusion of the calcaneocuboid joint is occasionally required.