Lunotriquetral coalition

Lunotriquetral coalition is the most common type of carpal coalition and represents a congenital fusion of the lunate and triquetral bones of the carpus;  prevalence of 0.1%. It is more common in females and African Americans.



Funny Looking Marrow (FLM)

Funny looking marrow is a common problem in MR imaging, particularly in the spine.   Some useful general guidelines are as follows:

  • T1WI signal
    • Should be higher than disk or muscle
  • Signal characteristics are variable depending on cellularity and microscopic fat
  • A good general rule of thumb comes from pathology
    • There should be 10% fatty marrow per decade
      • It follows that kids should have mostly red marrow
      • Nonagenarians should be 100% fatty
      • In practice, rarely this linear, but a good rule nonetheless
  • In phase/Out of Phase imaging utility
    • Relies on chemical shift
    • If there is signal drop out, benignity is much more likely because the dropout is caused by microscopic fat
    • No signal dropout means high cellularity which is associated with marrow replacement
  • Contrast Enhancement
    • Rarely useful
      • If neoplastic lesions are present, they are usually evident using above criteria
  • Canned DDx:
    • Heterogenous Marrow
      • Nonspecific heterogeneous bone marrow is present. This is commonly associated with anemia, cigarette smoking, chronic disease, and obesity.
    • Reactivation Red Marrow
      • Similar to above, but just add reactivation/reconversion.

Ref: AJR Am J Roentgenol. 2011 Dec;197(6):1298-308. doi: 10.2214/AJR.11.7005.
MRI of spinal bone marrow: part I, techniques and normal age-related appearances.



Parrot Beak Meniscal Tear

Many authors state that this term should not be applied in radiological clinical usage and the term should be reserved for the arthroscopist.  I am ambivalent on this stance in the true sense of the word.  There are compelling arguments on both sides.

In truth, a parrot beak is nothing more than a subclassification of  a radial meniscal tear.  Although uncommonly seen at MRI, this case is very good demonstration of that morphology.

The Oh-so-freqently-missed Posterior Shoulder Dislocation

Frequently missed and this case is no exception but they are often missed on plain film which this was not.  The plain film was the source of diagnosis with review of CT as restrospect.  Missed on CT which is significant error (not by me; in trauma, I explicitly comment on glenohumeral and hip joint location).


Unusual in that the films are pretty good for a trauma.  Reverse Hill Sachs fracture present.




Two Cases of AKI : Presumed Rhabdomyolysis in Military Patients

2 patients on 2 consecutive nights from a Naval Medical Center.

Both were stone studies, which was a reasonable clinical suspicion since that is probably the most common cause of flank pain. Both of them also presented with elevated creatinine precluding contrast out of concern for contrast nephropathy.

As an aside, acetylcysteine has no protective effects on the kidneys in the prevention of contrast induced nephropathy. I do not know of any institutions who were actually using this on a regular basis but from time to time it pops back up as a prophylactic measure in CIN. This was recently commented on in up-to-date.

What made me notice this “pattern” if you will, was that perinephric stranding is fairly uncommon in the young military population in the absence of chronic disease or urolithiasis. On seeing the 2nd case on a consecutive night, I did some digging to find out whether the previous case was actually the night before and from the same institution. The biggest concern in my mind was whether there was an epidemiologic issue such as HUS-TTP.

My suspicion is that it turns out it is an epidemiologic issue but unrelated to infection. Both patients reported to the emergency department with flank pain and no trauma after vigorous physical training (PT) workouts. They did have hematuria. Creatinine was above 2.0 in both patients. Although CT is unreliable, they both seemed adequately hydrated (IVC distention).

I would love to hear follow-up on these cases as it seems that this is probably rhabdomyolysis with acute renal injury secondary to vigorous exercise. I cannot remember seeing such a close association however the most likely thing is that this happens often and I simply miss it because the patients are not imaged or other people take up the studies.

For me it is a reminder that military training is not a benign process. To create the outstanding fighting force, young men and women not only sacrifice the best years of their life, they endure physical and psychological hardship for the benefit of the homeland.


Quadriceps Tendon Rupture

I have commented in the past that I read for several military hospitals as a part of teleradiology. In general, the physicians at these military hospitals appear far more judicious than other hospitals I have worked for (Moses Cone Hospital) in their use of imaging, particularly “high-end imaging”.

Private physicians have a low threshold for ordering advanced imaging which seems to be out of fear of litigation or patient demand. Regardless, this is a degradation of the physician’s fiduciary responsibility to the patient. This is an unfortunate reality of modern medicine. Unfortunately, this leads to greater expense and does not improve the quality of healthcare overall. This has been well demonstrated epidemiologically.

This is probably an effect of decreased threat of litigation and less practicing of defensive medicine than is seen in the civilian sector. This is a great example of appropriate use of imaging by a beleaguered overworked ER physician. The patient had compelling findings on the exam and was sent for MRI for orthopedic evaluation.



Although the amount of retraction is mild at the quadriceps tendon rupture, this is appropriate use of imaging because the sooner the tendon is repaired, the less retraction the surgeon has to deal with. With this workup in the night, the orthopedic surgeons can repair the tendon early the next day provided operating room space is available.


It makes me think that practicing medicine with the military is probably the closest the United States will ever come to a reasonable decision-making practice model and mitigate the effects of defensive medicine.