Epiploic appendagitis-Ultrasound

Young male with severe pain in the left iliac region. USG shows a well defined  hyperechoic noncompressible ovoid  mass close to the colonic wall - where patient had maximum tenderness.  No evidence of colonic wall thickening. Features S/O Epiploic appendagitis. Hypoechoic lesion appears to be the RING SIGN (as seen on CT); The ring represents thickening of the visceral peritoneum surrounding an inflamed epiploic appendix.

Case contributed by-

 Dr Ravi Kadasne, Radiologist

Emirates International Hospital Al Ain, UAE

Jejunal intussusception-Ultrasound

This is a case of jejunal intussusception in a child with abdominal pain (a case of gastroenteritis, pain was not much), Patient was scanned for good 15 minutes and it had reduced by then. Small bowel intussusceptions are incidentally detected, are without an identifiable pathological lead point, with a normal wall thickness, non-dilated proximal bowel and normal vascularity on color Doppler reduce spontaneously and are of no clinical significance. If not reduced till you finish the scan, follow up scan can b done after few hours.

Case contributed by-

 Dr Ravi Kadasne, Radiologist 

Emirates International Hospital Al Ain, UAE

Folded Gallbladder-Ultrasound

This Gallbladder is folded (a variation); and is shown well by the MPR images. Routine imaging of the gallbladder demonstrates a wide array of imaging variants, including anomalies in location, number, and configuration. An awareness of these normal variants may prevent misdiagnosis and will aid in evaluation of differential diagnostic possibilities.

Case contributed by-

 Dr Ravi Kadasne, Radiologist 

Emirates International Hospital Al Ain, UAE

Anomalous left coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery arising from the pulmonary artery; ALCAPA; ALCAPA syndrome; Bland-White-Garland syndrome. Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a heart defect in which the left coronary artery (which carries blood to the heart muscle) is connected to the pulmonary artery instead of to the aorta. This patient presented with effort intolerance and murmur. LCAPA can be diagnosed in an infant. However, this defect may not be diagnosed until someone is a child or adult. Also evident in this image are RCA to LCA collaterals. Dilated coronaries.

Contributed by Dr Rakesh Gopal , Apollo hospital Chennai 

(Consultant Interventional Cardiologist)

Studied Interventional Cardiology at Sree Chitra Tirunal Institute for Medical Sciences and Technology

H1N1 Vaccination & FDG PET

Recent article-  Clinical Nuclear Medicine: October 2011 - Volume 36 - Issue 10 - pp 848-853- has concluded "H1N1 vaccination can cause false-positive FDG PET/CT findings, when administered less than 14 days before the test, with the highest probability if the vaccination was administered less than 8 days ago. Increased FDG activity in the ipsilateral deltoid muscle is a key finding for accurate interpretation of increased FDG activity in axillary lymph nodes."

Seminal Vesicle Reflux

The seminal vesicles represent paired male organs which develop from the distal mesonephric duct, just proximal to the ejaculatory duct.  Causes associated with reflux not only into the seminal vesicles but also the prostate and vas deferentia, include urethral obstruction as in this case, patient had tight stenosis at the terminal portion of bulbar urethra.

Another Implant for the Radiologists-Spinal Cord Stimulator

An adult lady with  history of breathing difficulty  Chest X ray essentially is unremarkable other than  presence spinal cord stimulator (SCS).
By Dr MGK Murthy & Dr Sumer Sethi

What is SCS?

Also called dorsal column stimulator, is  device placed subcutaneously  to the  epidural location  to pass low voltage  current to better  manage pain

Components?

It has usually 4-16 electrodes, lead wire  that extends to pulse generator usually place under  the buttocks

How does  it work?

 When turned on with remote control(on req basis), it  stimulates the nerves in  dorsal cord to produce  tingling in the region of pain. The electric current  interferes with the passage of pain message to the brain. SCS does not eliminate the cause of the pain,it interrupts the pain signal from reaching  the brain. The goal of SCS is to reduce the pain signal by 50 -70 %.

Uses?  Indications?

Commonly resorted to when other pain management techniques have failed 

Useful in failed back surgery (40%of spinal surgeries may result in this ), any other refractory pain including ischaemic limb ,etc

 Future?

Being  tried in migraines and parkinsonism

Radiologists Role?

Suggest lead displacement/complications including infections, aspirations, lead migrations etc. MRI  is likely to be contraindicated and can produce  malfunction of the device 

Mummified Daughters of King Tutankhamun: CT

One of the recent uses of radiology includes using MDCT and reconstructions for archaeology. In a recent paper in AJR November 2011 vol. 197 no. 5 W829-W836, authors have used MDCT on the mummies of the daughters of King Tutankhamun and the images were reconstructed and subjected to forensic imaging analysis. This study ruled out skeletal congenital anomalies of one mummy which was suggested at past radiographic analysis. 

Stent Boost-For Cardiologists & Radiologists

StentBoost TM (SBTM) is a software developed by Philips. A short digital cine run is acquired with a deflated balloon in place. The software averages selected frames (centred on the stent) and creates an enhanced image improving signal-to-noise ratio. The gold standard evaluation method is IVUS, but routine use is costly and time-consuming. Stent boost is a new technique improving fluoroscopy-based assessment of stent expansion.

Till recent times, stents were not that clearly visible by conventional angiography. Now stents could be "boosted" without contrast, such that we can assess how well it is deployed.

Contributed by Dr Rakesh Gopal , Apollo hospital Chennai 

(Consultant Interventional Cardiologist)

Studied Interventional Cardiology at Sree Chitra Tirunal Institute for Medical Sciences and Technology

New Buzz word in CT technology-iterative reconstruction technique

       

CT radiation dose is an important issue in modern times, it is equally important to perform a high-quality exam that adequately addresses the clinical issues. Getting them both right is the new age demand- Problem is that the reduction in tube current and tube current voltage causes a resultant decrease in radiation dose, this also increases image noise. Philips now has a new approach which  uses a unique combination of low-kVp scanning and includes the iDose4 iterative reconstruction technique that improves low contrast sensitivity. 

Learning the Chest Skiagram-Still a long way to go

Middle aged lady with cough  shows- on  PA  chest ,a homogenous opacity  in the left mid  and lower zones with no significant air bronchogram or hilar prominence  or  CP angle blunting . There is silhouetting of the heart border  with no mediastinal shift or retrocardiac extension  of the opacity.  Rib cage and rest of the lungs are clear. Soft tissues   including the left breast shadow is symmetrical and normal. Lateral  X-ray shows the localization to lingual location possibly superior and greater fissure appears pushed backwards  by the  lesion. It  still shows no air bronchogram- diagnosis  should read as superior lingual pneumonia. Usual organisms that have predilection to this region are   oral commensals , and  non tuberculous mycobacteria (particularly avium) and legionella. Case submitted by Dr MGK Murthy.

·         Haemophilus influenza unlikely as  no fissural fluid is noted

·         Aspiration is les likely because of gravity nondependent position

·         Neoplasm is less likely as there  is more consolidation rather than collapse

·         Pleural etiology  is unlikely as the   fissure  or CP angle are   not giving the hint  and the lesion is not convex to the hilum if encysted 

Venous insufficiency & multiple sclerosis-MRI Images

 These are rather interesting MRI images sent to me by a friend Philip Chao,  his website www.3t-mri.net . Dr Philip W Chao has worked in Delaware to produce the best MRIs possible since 1990. He has monitored hundreds of thousands of MRIs over his career at the University of Pennsylvania and working for the people of Delaware. He is a board certified neuroradiologist and recently passed his maintenance of certification examination in 2006. He is also trained in body MRI and was the body MRI fellow at the University of Pensylvania from 1988 through 1990.  

These images show a rather unusual bullseye in the proximal right IJ vein, which could represent recanalized old thrombosis. Patient had MRI brain findings which may possibly indicate MS. And it is a image which makes one think about the coincidence of venous outflow obstruction and MS.

Further Reading- Chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Neurol Neurosurg Psychiatry 2009;80:392-399 doi:10.1136/jnnp.2008.157164. According to this paper-CDMS is strongly associated with CCSVI, a scenario that has not previously been described, characterised by abnormal venous haemodynamics determined by extracranial multiple venous strictures of unknown origin. The location of venous obstructions plays a key role in determining the clinical course of the disease.

Scimitar syndrome-CT Angiography

Scimitar syndrome, or pulmonary venolobar syndrome, is a rare congenital heart defect characterized by anomalous venous return from the right lung. The syndrome associated with PAPVR is more commonly known as Scimitar syndrome after the curvilinear pattern created on a chest radiograph by the pulmonary veins that drain to the inferior vena cava.This radiographic density often has the shape of a scimitar, a type of curved sword. These are classical CT images of the same.

Contributed by Dr Rakesh Gopal , Apollo hospital Chennai 

(Consultant Interventional Cardiologist)

Studied Interventional Cardiology at Sree Chitra Tirunal Institute for Medical Sciences and Technology

Grand Rounds-Indian Edition

For people who are new to this concept "Grand Rounds is a weekly summary of the best health blog posts on the Internet. Each week a different blogger takes turns hosting Grand Rounds, and summarizing the best submissions for the week. The schedule for Grand Rounds is available at the Better Health Blog and at Blogborygmi.com. Both Dr. Val Jones and Dr. Nick Genes coordinate the schedule for Grand Rounds.”

I had the honour of hosting these grand rounds earlier in 2005, and yours truly was the host for the 21st edition of this rounds.  Medblogging has surely come a big way since then. In my own blog for past 7 years now, I have been sharing interesting radiological cases, current updates, resident-professor series (where we explain the case as if in a class room) and quizzes at times.  Another change which I have observed in recent years is the impact of facebook on blog traffic. I think we need a more active medical grand rounds page on facebook. My suggestion- we should all share each edition of grand rounds on our facebook pages as well as our blogs for more viewership. My thanks to all those who submitted to this edition and  Grand Rounds Surely Rock. 


Incidentally next week in India we are celebrating Diwali, Diwali popularly known as the "festival of lights", is an important festival in India. In the rradition and story of Deepawali lies the significance of the victory of good over evil; and it is with each Deepawali and the lights that illuminate our homes and hearts, that this simple truth finds new reason and hope. Wish you all Very Happy and Prosperous Diwali.  Keep MedBlogging!!

In this edition of the grand rounds in addition to the compilation of the prominent posts from the blogosphere, I will add a touch of tourism for all those who know little about India. If someone in India is asked to name two most prominent things or figures in India- most probable answer will include- Taj Mahal and Mahatma Gandhi.  I will start with one and end the rounds with other.

The Taj Mahal is a white Marble mausoleum located in Agra, India. It was built by Mughal emperor Shah Jahan in memory of his third wife, Mumtaz Mahal. Taj Mahal is the finest example of Mughal architecture, a style that combines elements from Persian, Turkish and Indian architectural styles. In 1631, Shah Jahan, emperor during the Mughal empire's period of greatest prosperity, was grief-stricken when his third wife, Mumtaz Mahal, died  Construction of the Taj Mahal began in 1632. The court chronicles of Shah Jahan's grief illustrate the love story traditionally held as an inspiration for Taj Mahal.

Source information and images-Wikipedia

http://en.wikipedia.org/wiki/Taj_Mahal

Editor’s Pick

Dr Charles who had incidentally submitted to my previous edition of grand rounds as well has submitted a post containing two medical poems from a poetry contest on his site.

Healthcare Insurance and Business Section

1. Henry Stern in his blog InsureBlog has his comments on AMA Ad campaign titled Commercial Hypocrites
2. From Beyond the Clinical there is a post which talks of three Levers of Healthcare Profit which you need to Pull Them to Stop Losing Money. It is about what to do when the line in your waiting room goes out the door, appointments are delayed, reimbursement decreases and regulations increase.
3. John A. Hartford Foundation blog Health has requested input from readers as to the most pressing problems in health and aging as the foundation formulates a new strategic plan.
4. The Happy Hospitalist has post about What can doctors learn from the airline industry?
5. From Colorado Health Insurance Insider has a thought provoking post which asks- Are some clinics artificially inflating their billed amounts just so that they can say that Medicare is dramatically underpaying them?  Who knows.  It’s hard to see how costs for the same basic set of services could actually vary by that much from one location to another. Aptly titled- The Opposite of Transparent

Health 2.0

1. Jan Gurley has a  submission about a presentation and demonstration at Health 2.0 from Mindbloom called 'The Farmville of health'
2. Laika's MedLibLog has post about Evidence Based Point of Care Summaries.  It goes on like- For many of today’s busy practicing clinicians,      keeping up with the enormous and ever growing amount of medical information, poses substantial challenges. Its impractical to do a PubMed      search to answer each clinical question and then synthesize and appraise      the evidence. Incidentally, she is our host for the next grand rounds. Call for submission for the next rounds is here.
3. Dr. Bertalan Mesko from Webicina.com has an interesting post Social Media and Medicine in India 

Physician’s Section

1.    According to ACP Internist-more research suggests that chocolate seems to lower the risk of stroke, according to a Swedish study that found that women who ate 66.5 grams each week, or about two chocolate bars, had a 20% lower risk.
2.       Val Jones has post about sports vision - and it links to her recent podcast interview with medical experts who describe eye exercises for athletes (who knew there were such things?)
3.  Another teaching post on Ankylosing Spondylitis (and spondyloarthritis) for both patients and educators.
4.    From Medrants this week is a post called Diagnostic Skepticism – the most valuable trait,  author talks about diagnostic errors encountered as an internal medicine attendee- Sometimes the patients have received an incorrect label from the emergency department; sometimes another internist or subspecialist has provided the wrong label; sometimes their primary care physician has mislabeled the diagnosis.
5.    Dr Pullen in his post Keeping Perspective: A Key Role for the Family   Physician, believes that one of the most important things he offers to his  patients is help in keeping perspective when making medical decisions.
6.    Michael Kirsch in his post asks a very pertinent question- Why are antibiotics prescribed so casually and so frequently?

Surgeon’s Section

1. Elaine Schattner from Medical Lessons in her submission talks of differences between Prostate and Breast Cancer Screening and says that mammography and PSA testing can't be lumped together in a simple dismissal of all forms of cancer screening.
2. Paul S. Auerbach, MD in his post talks of The Concept of Risk in outdoor activities with interesting starting line- "Risk more than you can afford to lose, and learn the game!"

Medical Students & Intern’s Section

1. Relatively new blog about funny things in intern year and residency has an interesting post called statement of will.
2. Another post about the first surgical case in which author was allowed to scrub in on during my Surgery clerkship.

Mental Health

1. Barbara Kivowitz has on her blog beautiful post regarding sharing your worry
2. Will Meek PhD has a post describing the  dependency needs, which are basic needs we all have that we cannot provide ourselves. These include companionship, affection, and emotional support. This post discusses these needs, and what can happen if they are not adequately met.
3. There is this post about upcoming series of book discussions with the authors of some of the best brain health books selected by AARP.
4. Here is a post from Sam Ko, MD in the topic of WORK-LIFE balance

Patient’s Section

1. Faun and Me, is the true story about losing author’s good friend Faun to metastatic breast cancer. This narrative is an example of the seriousness of metastatic disease in light of all the feel-good positive pink ribbon campaigns this month.
2. From the Society for Participatory Medicine's blog: there is a post called “When I became a patient, I felt my identity slipping away.”

Miscellanous Posts

1. The Covert Rationing Blog this week has a post that illustrates how, in the US, “diversity” is the uber-virtue, from which all the subsidiary virtues (faith, hope, charity &c.) must necessarily spring.
2. There is a post from Jessie Gruman, called “Contagion: Action! Adventure! The Value of Science?” which uses the recent movie Contagion as evidence of why our Federal government, scientific research, and science-based knowledge are so important, especially in real-life health care situations.
3. Toni Brayer, MD from  EverythingHealth has a post about  land mines and associated global problem that all nations should be addressing.
4. Pranab Chatterjee has a critical summary of the second episode of the new season of House MD, focusing on the veracity of the medical contexts presented in it to create the drama. Although the show in itself is a huge commercial success, unfortunately, this particular episode was rather disappointing

Mohandas Karamchand Gandhi was the pre-eminent political and ideological leader of India during the Indian independence movement. A pioneer of satyagraha, or resistance to tyranny through mass civil disobedience — a philosophy firmly founded upon ahimsa, or total nonviolence — Gandhi led India to independence and inspired movements for civil rights and freedom across the world.

Source information and images-Wikipedia

http://en.wikipedia.org/wiki/Mohandas_Karamchand_Gandhi

New KLAS report on Teleradiology

 "Nearly a year ago Virtual Radiologic (vRad) announced their acquisition of NightHawk–the largest teleradiology firm in the U.S. Since that time, teleradiology customers have been questioning how the acquisition would affect them and the market. To better understand the impact, KLAS embarked on a new teleradiology study called Teleradiology Services 2011: Times are Changing."

PCA Infarct-MRI

Clinical Data: Young adult presents with history of headache and seizures. MR shows acute  non-hemorrhagic stroke of right PCA possibly involving P-2 segment. 

Teaching points by Dr MGK Murthy

·         PCA arises from top of basilar and supplies midbrain, subthalamic nucleus, basal nucleus, thalamus, mesial inferior temporal  cortices

·         Additionally via PCOM, supplies collateral circulation to MCA territory

·         Divided by PCOM in to P1 (including thalamogeniculate ,splenial and medial as well as lateral posterior choroidal arteries) and P2 segments (posterior temporal and internal occipital)(P2A=crural cistern segment, bridges with posterior P2P Ambient cistern component)

·         P3 segment of PCA  refers to  quadrigeminal segment and P4 is cortical segment

·         Prominent Laterality of P4 segment  is   a  reliable sign of collateral circulation positivity,  from leptomeningeal anastomosis (200to 600 microns in size) M1 segment  block  of MCA , (starts in hours and peaks in days or weeks )on MRA

·         Variant include fetal PCA (absent or hypoplastic P1) (30%)and central artery of Percheron (Bilateral  ,medial thalamic and rostral midbrain perforators arise from single ,unilateral , common, P1segment)

·         Etiology of stroke are like elsewhere , with cardiogenic embolization and dissection of proximal vessels  as well as migraine(70% occur only  in patients  with aura) preferentially involving PCA 

Os Peroneum Fracture-Plain Film

An adult patient presents with acute trauma to lateral foot with tenderness near cuboid. X ray shows  irregular, fragmented and possibly spread out appearance of osperoneum with Soft tissue swelling in the vicinity  with spurring at cuboid peroneal groove location- comminuted fracture of os-peroneum with peroneus longus tendon rupture is possible. MRI  would help.

Teaching points by Dr MGK Murthy

·         Os-peroneum is round or oval  accessory ossicle located at calcaneocuboid junction level in the distal peroneus longus tendon substance

·          Peroneus longus originates from lateral tibial condyle and head of fibula, travels along the retromalleolar groove of fibula protected by superior peroneal  retinaculum (SPR), and inserts in to 1^st MT base  and medial cuneiform (brevis  comes from mid 1/3 leg and goes to  base of 5th MT)

·         Seen in 26% of feet , though some differ from these figures

·         Fractures can occur due to direct trauma or indirect stress due to forced dorsiflexion of foot

·         Fragments spread along the  longus tendon and are often accompanied by tendinopathy or rupture

·         Differentials include more common bipartite os-peroneum, and degenerative process of the ossicle

What do we dislike most about the Examiners in Radiology in India?

ü  When he says – we are here to help you.

ü  When he says-  by failing you I am helping you.

ü  When he says- most of these youngsters don’t deserve to pass.

ü  When he says- did you ever see x-rays in your residency?

ü  When he says- standard of this exam is maintained by the poor passing percentage (guess which exam is this?)

ü  When he says I am giving you a hint and you cannot see it!

ü  When he says I am being very lenient with you, try once more

ü  When he says he is getting late for his flight/train back home.

ü   When he says-even if you don’t know the diagnosis, give a broad differential, which organ do you think is abnormal- suddenly you feel you have got it all wrong so far.

ü  When he says- ok even if you don’t know much about this just tell me this basic concept about this procedure (interventions!!)

ü  When he says- I understand this modality is not available in your parent institute but you must have read about this in your books.

ü  When he says-to the  other examiner, see I told you this guy doesn’t know radiology

ü  When he says-to the other examiner, remember last time we passed only 3/10 candidates

Time to make our exam systems more HUMAN.

-One suggestion for exams is –Instead of examiner bringing cases from his collection lets have third party bringing cases which examiner and candidate are both evaluating together and even if the candidate gets it all wrong but his findings are comparable to the examiner, he still passes. To me passing should not mean diagnosing a weird case but having similar approach to practicing radiologists. And by having a third party case, we make examiners also blinded to bias which comes with knowing the correct diagnosis before hand.  Alll thoughts, comments and suggestions are welcome.

Medical Grand Rounds Come to India-Submissions Requested

Grand Rounds is a weekly summary of the best health blog posts on the Internet. Each week a different blogger takes turns hosting Grand Rounds, and summarizing the best submissions for the week. 


Dr. Val and Dr Nick Genes were kind enough to provide me this opportunity, I'm Sumer Sethi  and  I am your host for the medical grand rounds on October 18th. I'm accepting submissions for just about anything. If you have something to contribute, please feel free to email it to me (anything…links, blog posts, poems, videos, funny stuff you've found) and I'll be happy to include it. Also, if there's anything you might be able to do to promote the grand rounds for the 18th, I'd be grateful for help in spreading the word. The web address for my blog is http://sumerdoc.blogspot.com and thanks again. 


I had the honour of hosting these grand rounds earlier in 2005, and i was the host for the 21st edition of this rounds.  Medblogging has surely come a big way since then.

Email your submissions to me at sumerdoc@yahoo.com and make sure you have grand rounds submission in the subject of the mail. 

Calcific Periarthritis-Plain Film

An adult female with  sudden onset juxta articular pain near the MCP joint of digit  with no history of trauma. X ray shows subtle soft  homogenous and amorphous calcification in the juxta articular location with no significant periarticular demineralization, Soft tissue swelling or widening of the  joint, typically favoring  acute calcific  periarthritis. MRI helps by showing abnormal soft tissue with foci of low signal corresponding to the calcification and  exclusion of the differential diagnosis

Teaching points by Dr MGK Murthy. Edited by Dr Sumer Sethi.

Acute calcific periarthritis  is a form of hydroxyapatite  deposition disease   with soft amorphous calcification localized to the site of clinical pain particularly in pre and perimenopausal women

·         D/D includes Heterotopic calcification/accessory ossicles (presence of cortex and internal trabeculation),CPPD deposits (presence of chondrocalcinosis),Gout (erosions and serum uric acid help),Metastatic  periarticular calcification like hyperparathyroidism, Endstage renal disease ,Tumoural calcinosis, and hypervitaminosis etc show multiple sites ,synovial sarcoma(presence of osteoporosis, psammamatous /peripheral calcifications, and extensive soft issue swelling) and of course pyogenic  tenosynovitis with no characteristic X ray findings. 

Vallecular Cyst-CT

Laryngeal cysts are rare laryngeal lesions. It is estimated that 10.5% of laryngeal cysts occur in the vallecular space. Vallecular cysts (VC) have been reported in literature under other names, such as mucus retention cyst, pre‐epiglottic cyst, epiglottic cyst, base of the tongue cyst, and ductal cyst.  This is probably due to the confusion surrounding the pathogenesis and aetiology of this lesion. Adult patients with a VC generally have a benign course and commonly present with symptoms of hoarseness, foreign body sensation and dysphagia. This is 30 year old male patient with hoarseness.

High Strength MRI causes Vertigo

There is some concern by people regarding  people feeling dizziness  in newer high-strength MRI scanners. Study published online September 22, 2011, in the journal Current Biology it has been suggested that magnet pushes on fluid that circulates in the inner ear’s balance center, leading to a feeling of  unsteady movement. 

Reference- Johns Hopkins Medical Institutions (2011, September 23). Researchers pinpoint the cause of MRI vertigo: Machine's magnetic field pushes fluid in the inner ear's balance organ. ScienceDaily. Retrieved October 9, 2011, from http://www.sciencedaily.com­ /releases/2011/09/110922134529.htm

Diabetic Foot For Radiologist

An elderly diabetic lady  presents with painful and swollen foot. Resident-Professor series by Dr MGK Murthy & Dr Sumer Sethi

(a)What do the X rays show ?

They show subluxations, lucencies or bones, irregularity, periosteal reaction, and Soft tissue  swelling

(b)What are the possibilities ?

 The possibilities  are Charcot’s arthropathy and osteomyelitis in diabetes

In this case  presence of ulcer, lucencies, and no fragmentation or dislocation support osteomyelitis

(c ) How do we differentiate ?

It is big clinical dilemma as both present with hot swollen foot  in diabetes. Usually infection always  reaches the bones via skin  ulcer and the presence or absence of the same is vital . Increased Blood counts and C Reactive protein positivity, absence of bilaterality help further. Presence of fragmentation and dislocations  suggest Charcots. Charcots being autonomic neuropathy presents with fragmentations, fractures, sclerosis,  and subluxations 

(d)What is the etiology of charcots?

Not known exactly . However some believe sensory neuropathy contributes by ulceration not noticed by the patient (neurotraumatic theory) and other autonomic neuropathy leading to increased blood flow and thereby the mismatch between bone synthesis and destruction

Scapholunate Dislocation-Plain Film

10 yr old child with history of fall and dorsal scapholunate tenderness  shows  loss of prescaphoid fat planes , increased scapholunate distance  with possible lunate extension and scaphoid flexion, suggesting scapholunate instability. Stress view with traction applied to thumb (5Kg) and other side comparison would help.

Teaching points  by Dr MGK Murthy.

·         Scapholunate instability is  most common and most significant carpal instability.  Predisposition occurs in negative ulnar variance, radial articular surface sloping, and lunotriquetral coalition.  Dorsal scapholunate tenderness is the clinical sign  for suspicion

·         Labeled chronic(>6wks), subacute(1-6weeks), and acute(<1week), with delayed diagnosis leading to Scapho Lunate Advanced Collapse (SLAC)

·         Resting PA wrist  is suggestive  -scapholunate gap is> 3mm =suspicious and if >5mm= diagnostic (Terry Thomas sign) , scaphoid ring sign(distance between proximal edge of the ring to the ulnar corner of scaphoid is <7mm),Traingular shaped lunate(extended),reduction in carpal height ratio( <0.54)

·         Lateral X –ray ----scapholunate angle >60 degrees is probable, >80 degrees is definite, lunate extended, lunocapitate angle >15 degrees

·         If  routine x -rays  negative, stress views –ulnar deviation PA  or AP clenched fist views would help

·         Some advocate dynamic  thumb traction(5Kg) and fluoroscopic spot film, to see increased SL distance or difference of more than 1mm  with resting view

·          Conventional /MR Arthrogram would help with Arthroscopy as gold standard

MRI in Azoospermia-Interesting Case Report

36 years old male with primary infertility being investigated with CT scan being normal and azoospermia. MR of the region of interest suggests normal KUB, two relatively well defined small (less than 5 mm) cysts seen on either side of the midline symmetrically at the level of the ejaculatory ducts opening. The seminal vesicles are not identified. A convoluted fluid signal intensity heterogeneous lesion on the left, could represent dilated vas deferens.  Right vas, is not identified.   Rest of the study including the prostate gland and the testes are unremarkable. Transrectal ultrasonography corroborates the same.

Teaching Points:

Dr MGK Murthy, Dr Sumer Sethi. 

Contributors- Mr Hariom, Mr Gupta.

Ejaculatory ducts (ED) are, paramedial symmetrical structures, located in the central portion of the prostate in verumontanum region. Act as conduits through which vas deferens and seminal vesicles fluid enters prostatic urethra during ejaculation.

Obstruction to ED could be congenital or  acquired (Post urethral catheterisation,  uretheritis, TURP and Idiopathic), as well as complete or  incomplete.

D/D  includes  Mullerian duct cysts (can reach very large size and present as pelvic masses, usually in midline with no sperm on aspiration, can obstruct the ED opening by their size), Utricle cyst (small, not beyond the prostate usually, and in the midline), Prostatic retention cysts (seen usually in BPH, as cystic dilatations of prostatic acini of 2 to 6 mm size in central zone or central / peripheral zone junction), Seminal vesicular cysts ( small, less than 5 cms, occur in inflammatory and obstructive conditions, associated with renal agenesis), Ejaculatory duct cysts (cystic structures along the course of the ED just lateral to the midline at the verumontanum, with definitive diagnosis possible by trans-rectal aspiration showing sperms).

Treatment includes : Transurethral resection of the ejaculatory duct cysts with good results. However in our case reconstruction would be needed in view of possible absence of right Vas and both seminal vesicles.