218 CORRESPONDENCE

Rees and Whyte (1989) also suggested that early spleno-renal shunting decompresses the portal system and prevents the formation of varices. This may well be correct as in our patient the formation of varices extending the length of the oesophagus was partly due to obstruction of the SVC. The pattern of enhancement demonstrated that they drained inferiorly, i.e. 'downhill ' varices. These usually involve only the upper one-third of the oesophagus if the SVC obstruction is above the entrance of the azygos vein and the upper two-thirds if the SVC obstruction is below the azygos arch. Collaterals by-passing the IVC obstruction may drain into the oesophageal veins (Ferris et al., 1969) and this may account for his varices extending into the lower oesophagus.

Further study is necessary from a centre specialising in hepatic disease to assess splenic size in portal hypertension in the presence of spleno- renal shunting to determine whether or not a spleen of normal size indicates splenic pathology.

M. J. CHARIG J. E. S. HUSBAND

References

CRC Radiology Research Group Department of Radiology Royal Marsden Hospital

Sutton Surrey SM2 5PT

Ferris, EJ, Hipona, FA, Kahn, PC, Philippa, E, Shapiro, JH (1969). Venography of the Inferior Vena Cava and its Branches. pp. 53-63. Williams & Wilkins Co, Baltimore.

Kaplan, HS (1980). Hodgkin's Disease. 2rid Ed, pp. 282-283. Harvard University Press, Cambridge, Massachusetts.

Rees, JIS & Whyte, AM (1989) Case report: Portal hypertension with a large spontaneous spleno-renal shunt in the absence of splenomegaly Clinical Radiology, 40, 431 433.

ARE THREE VIEWS NECESSARY TO EXAMINE ACUTE ANKLE INJURIES?

S IR- I was interested in the paper by Wallis (1989). The rather predictable results are I suspect of little relevance to most Casualty Departments in the UK which would only routinely request on AP and lateral film of an acute ankle injury. It is not surprising that an additional view revealed a small number (4 7%) of unsuspected, but insignificant fractures as would be expected of other anatomical sites, e.g. the elbow and thoracic cage.

It would be interesting to know in the light of recent literature on acute ankle radiography (Brooks et al., 1981; Dunlop et al., 1986) why the author's hospital had a policy of requesting three ankle views in the first place?

J. G. MOSS

References

Department of Radiology Royal Infirmary of Edinburgh

Lauriston Place Edinburgh EH3 9 Y W

Brooks, SC, Potter, BT & Rainey, JB (1981). Inversion injuries of the ankle: clii~ical assessment and radiological review. British Medical Journal, 282, 607-608.

Dunlop, MG, Beattie, TF, White, GK, RAAB, GM & Doull, RI (1986) Guidelines for selective radiological assessment of inversion ankle injuries. British Medical Journal, 293, 603 605.

Wallis, MG (1989). Are three views necessary to examine acute ankle injuries? Clinical Radiology, 40, 424-425.

SIR In reply to Dr Moss I am unfortunately not in a position to comment on the routine ankle series performed "in most Casualty Departments in the UK'. At the time of writing this paper four of the six

departments on the 'Birmingham Teaching Circuit' provided three views. I am pleased to note that at least one is now moving towards changing this policy.

In 1983 worldwide the average number of routine films obtained for a patient with ankle trauma was 2.5 and 2.9 for the United States (Cockshott et al., 1983).

The X-ray department at East Birmingham Hospital has provided three views for acute ankle trauma in the belief that this afforded more diagnostic information. The work quoted by Dr Moss offers guidelines on which patients should be radiographed (or more accurately which patients can be safely left without radiography). Neither paper considers the actual views taken or their relative merits.

M. G. WALLIS Coventry and Warwickshire Hospital Stoney Stanton Road

Coventry CV1 4FH

Reference

Cockshott, WP, Jenkin, JK & Pui, M (1983). Limiting the use of routine radiography for acute ankle injuries. Canadian Medical Association Journal, 129, 129-131.

BENIGN BREAST CHANGE

Sm The working party and the Royal College of Radiologists Breast Group (1989) are to be congratulated on their clarification of this complex and difficult problem. Their projected standardisation of the radiological report is most welcome as the multiplicity of radiological descriptive terms is such that comparison of reports from different centres is virtually impossible. With the extension of breast screening programs the need for reports which allow meaningful comparisons to be made is obvious. Equally the need for such standardised reports in the teaching of mammographers is essential. The standardised report suggested is, however, flawed in that it makes no mention of the skin and nipple shadows, structures which should be the first comment in the report. Whilst changes in these structures may perhaps be of more importance in malignant disease they should not be overlooked in benign breast change. Changes in the nipple shadow; cracked nipples, accessory nipples and retraction associated with sclerosing adenitis are important in the mammographie image.

Equally skin changes such as seen in infective mastitis and less so in plasma celled mastitis may be important clues in diagnosing changes occurring in the fibroglandular tissues of the breast.

To omit comment on these structures from a standardised report or from the teaching of trainee mammographers would be a mistake.

E. SAMUEL Department of Radiology University of Pretoria and Brentherst Clinic

Republic of South Africa

Reference

Breast Group of the Royal College of Radiologists (1989). Radiological nomenclature in benign breast change. Clinical Radiology, 40, 374- 379.

SIR The purpose of our study was to define the parenchymal patterns in benign breast change, and to seek to offer a simple classification of these. Although changes in the skin and nipple are important in carcinoma of the breast, they are much less so in benign breast change, and, for this reason, they were not included in the paper. However, 1 see no reason why these should not be added at a local level.

P. B. G U Y E R Department oJ'Radiology Royal South Hants Hospital

Graham Road Southampton S09 4PE