August 14, 2014

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Maisonneuve Fx…

This patient presented to the ED after twisting their ankle playing basketball.  Notably on clinical exam the patient also had pain to palpation near the proximal lower leg:

 

Massoneuve Fx 2

Massoneuve Fx 3

These radiographs show two clearly visible fractures on the proximal and distal fibula.  Also noted is some widening of the mortis on gravity stress view and if you look closely on the anterior tib/fib image (top) there is a comminuted proximal tibia fracture.  The injury pattern seen here is an example of a Maisonneuve type fracture.

A Maisonneuve fracture occurs when with disruption of the distal tibiofibular syndesmosis is associated with a proximal fibular fracture.  Often a medial malleolar fracture will be seen as well (not in this image).  This is an unstable fracture pattern that often needs operative intervention.  This image has an additional proximal tibia fracture that isn’t usually classic for a Maisonneuve fracture pattern.

In order not to miss this fracture one should always perform a proximal lower leg exam with all ankle injuries!  Image the entire fibula if there is pain.

Author:  Russell Jones, MD

 

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August 7, 2014

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WWWTP #20 Answer…

This patient presented to the ED with a headache.

delta-sign

 

This patient has an “Empty delta sign” in the superior sagittal  sinus (blue arrow).  This is indicative of dural venous sinus thrombosis.  There is a clot (dark) among normal blood in the sinus (light).  Remember to look at your sinuses for this rare occurrence.

Image Contributor:  Adriel Watts, MD

Author:  Russell Jones, MD

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August 4, 2014

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WWWTP #20 (What’s Wrong With This Picture?)…

This patient presented to the ED with a headache.  What’s Wrong With This Picture?

WWWTP #20

Image Contributor:  Adriel Watts, MD

Author:  Russell Jones, MD

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July 31, 2014

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What are these devices? Answer…

Question earlier this week:  “There are two devices entering the mediastinal structures from below…what are they?”

IABP 2

iabp-2

There are a bunch of devices on this radiograph.  Here they are by color:

1.  Orange arrow:  A Swan-Ganz catheter coming up from the femoral vein

2.  Red arrow:  Intra-aortic balloon pump coming up from the femoral artery

3.  Green arrow:  External monitor cables extending to the various monitor points on the patient externally

4.  Blue arrow: Dialysis catheter coming from the right internal jugular vein

Admittedly, this is not your usual ED-based radiograph.  This patient was presented with a STEMI and in cardiogenic shock.  This was a radiograph obtained later in the cardiac ICU after coronary intervention.  The Swan-Ganz catheter is unclear if it is in proper position (pulmonary artery).  Usually Swan-Ganz catheters (AKA pulmonary artery catheters) are placed from the superior circulation and loop into the pulmonary artery.  This was placed under fluoroscopy while performing a coronary artery intervention in the cath lab; I’m not sure where the tip is located based on this radiograph.

Author:  Russell Jones, MD

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July 28, 2014

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What are these devices?

There are two devices entering the mediastinal structures from below…what are they?

IABP 2

 

Answer to follow!

Author:  Russell Jones, MD

July 21, 2014

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Not your ordinary arm fracture…

This patient was shoveling, had sudden onset of forarm pain…

Radius fx 2 radius fx

This is a pathologic fracture from a forearm malignancy.  The patient’s primary malignancy was rectal adenocarcinoma.  This is a rare place for a metastasis.

The mechanism for this patient did not support a broken bone.  However one should keep in mind pathologic fractures when deciding whether to obtain plain films.  Plain films in the ED are quick, inexpensive, and don’t come with significant radiation risks.  I usually argue these points with my residents when discussion about plain film utilization in musculoskeletal pain.

Author:  Russell Jones, MD

July 14, 2014

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Liver mass…differential diagnosis

This patient presented with right upper quadrant pain.  I asked last week what your differential diagnosis would be:

Liver Mass 1

Liver mass 2

The CT above shows a multiloculated, rim-enhancing mass in the liver parenchyma.  This is consistent with an abscess.  The differential diagnosis starts by breaking down the categories into bacterial, fungal, and amebic causes. 

Bacterial:  Abscesses can form from ascending cholangitis, especially in setting of biliary malignancies.   Klebsiella pneumoniae has been reported to cause hepatic abscesses, especially in E. Asia (1).  Patients with recent instrumentation (hepatocellular carcinoma embolization, etc) are at risk for MRSA, streptococcus species.  Tuberculosis has been known to cause hepatic abscesses as well.

Fungal:  Disseminated candidiasis in the immunocompromised host can lead to liver and splenic abscesses

Amebic:   Liver abscess is the most common manifestation of extraintestinal entamoeba histolytica (2).  In endemic areas or travelers to endemic areas are at risk for this occurrance. 

Author:  Russell Jones, MD

References

1.  Davis J, McDonald M.  Pyogenic Liver Abscesses.  www.uptodate.com

2.  Leder K, Weller P.  Extraintestinal Entamoeba Histolytica Amebiasis.  www.uptodate.com

 

July 7, 2014

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Liver mass…

This patient presented with right upper quadrant pain…

Liver Mass 1

Liver mass 2

The CT above shows a multiloculated, rim-enhancing mass in the liver parenchyma.  What is your differential diagnosis?

Author:  Russell Jones, MD

June 30, 2014

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WWWTP #17 Answer…

This is a pediatric radiograph of a patient with wrist pain after a fall:

SHII fx distal radius II SHII fx distal radius

 

There is a subtle linear lucency on the distal radius, best seen on the lateral view.

This is a Salter-Harris Type II Distal Radius fracture.  For a refresher on Salter-Harris classification see:

Salter-Harris

Author:  Russell Jones

References

1.  Salter-Harris Fracture.  http://en.wikipedia.org/wiki/Salter–Harris_fracture

June 23, 2014

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What’s Wrong With This Picture #17 (WWWTP?)

This is a pediatric radiograph of a patient with wrist pain after a fall:

SHII fx distal radius II SHII fx distal radius

What’s Wrong With This Picture?

Answer to follow.

Author:  Russell Jones

 

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