April 14, 2014

0 Comments

Central line complication…

Central line mishap 1

Central line mishap 2 Central line mishap 3 Central line mishap 4

Central lines are often necessary and performed quite frequently.  With frequent procedures sometimes we get comfortable performing them and we minimize possible dangers.  This case demonstrates, however, that there are real complications that can occur from our invasive procedures.  Thus it is important to weigh the risks and benefits.

This central line decided to go through the caudal portion of the brachiocephalic vein and into the mediastinum.  The first xray shows the end of the catheter kinked near the aortic root.  CT of the chest shows the distal tip of the catheter puncturing through the vein and into the mediastinum.  Obviously this is a very rare complication!

Image Contributor:  Aaron Hougham, MD

Author:  Russell Jones, MD

 

Continue reading...

April 7, 2014

0 Comments

Reasons not to try relocation of hips…

Dislocated hip

On this pelvis Xray you can see two hip replacements, the left one is dislocated.  If you look closely you can also see a fracture line just superior to the prosthesis near the greater trochanter.  Be careful reducing these without obtaining orthopedics input. 

The other prosthesis is interesting.  It is a hip replacement with a constrained acetabular liner.  You can see a radioopaque ring around the femoral head component of the arthroplasty.  This is a ring that functions to hold the hip in place.  If this dislocates (not in this case), then this requires open surgical intervention for relocation.  Don’t try to put one of these back in!

Image Contributor:  Hollis “Tag” Hopkins, MD

Author:  Russell Jones, MD

References

1.  THR: Constrained Acetabular Liners.  http://www.wheelessonline.com/ortho/12698

Continue reading...

April 3, 2014

0 Comments

Multiple masses chest..

Late 20s male presents with shortness of breath…

Chest masses Chest masses CT

This Xray and CT show a phenomena called “Cannonball Metastases.”  This refers to innumerable descreet masses in the chest.  Two tumors are highly suspected in this case: renal cell carcinoma and choriocarcinoma.   Others that have a higher prediliction to multiple lung mets are prostate, endometrial, and synovial sarcoma (1). 

This patient ended up having a choriocarcinoma of the testes. 

Image Contributors:  Kevin Murphy, MD and Mary Bing, MD

Author:  Russell Jones, MD

References:

1.  Knipe H, Bickle I, et al.  Cannonball Metastases. www.radiopaedia.org

Continue reading...

March 31, 2014

0 Comments

WWWTP #15 Answer…

Several days ago this CXR was posted:

WWWTP #15

This CXR has several interesting findings.  There is a heavily calcified mass in the left hilar region consistent with a calcified lymph node.  Also there are multiple discreet nodules in the lung parenchyma (best one is seen in the left upper lobe, also well seen in right middle and upper lobes). 

Turns out this patient had lived in the midwest region for most of his life.  This pattern can be seen with Histoplasmosis. 

Histoplasma capsulatum is a fungus that is highly prevalent in the Ohio and Mississippi valleys of the midwest.  Radiographically it commonly causes solitary pulmonary nodules, multiple tiny nodules (miliary Histoplasmosis), and lymphadenopathy.  Less commonly it can cause fulminant pneumonia.  The differential diagnosis, depending on the radiographic findings, can include Mycobacterium tuberculosis, Coccidioidomycosis, lung cancer, lymphoma, sarcoidosis, and others. 

Author:  Russell Jones, MD

Continue reading...

March 27, 2014

0 Comments

WWWTP #15 (What’s Wrong With This Picture?)

This patient is a middle-aged male presenting with a chronic cough:

WWWTP #15

What’s wrong with this picture and what is your differential diagnosis?

Answer to follow.

Author:  Russell Jones, MD

March 24, 2014

0 Comments

Abdominal pain…

Patient had RLQ abdominal pain, we obtained a CT looking for appendicitis:

Pill frags 1

The patient has multiple, radiodense objects throught the small bowel.  Upon further history this patient was taking multiple calcium and iron supplement pills a day. 

Author:  Russell Jones, MD

March 19, 2014

0 Comments

Bad orthopedics…

A patient presents with foot pain after a fall from a ladder:

Foot fracture 1 Foot fracture 2

This foot X-ray shows a hindfoot dislocation at the talo-navicular and calcaneo-cuboid joints with varus angulation.  This pattern is suggestive of a Chopart’s fracture/dislocation.

What is a Chopart’s fracture/dislocation?  Glad you asked!  It is a dislocation at the specified joints above (talo-navicular and calcaneo-cuboid).  This hindfoot joint is commonly referred to as the Chopart joint.  Please see radiopaedia.org for further discussion and an even clearer X-ray for educational purposes:

Chopart’s Fracture/dislocation

It is important to understand that this is a HIGH energy mechanism.  With these high energy mechanisms it is also important to consider other injuries including proximal tibia, hip, and lumbar spine injuries.  This patient also had:

Tibial plateau fx 2 Tibial plateu fx 1

This is a quite comminuted fracture of the tibial plateau that may even make an orthopedic surgeon cringe.

Author:  Russell Jones, MD

March 11, 2014

0 Comments

Device for spasticity…

Here is a CT (with scout film) showing a not-to-uncommon device placed in the abdominal wall:

Baclofen 1 Baclofen 2 Baclofen 3

This is an example of an intrathecal pump, commonly used to deliver baclofen.  The first image shows the pump tubing coursing on the abdominal wall, into the thecal space (inserting just lateral to the spinous process of the lumbar vertebrae).  The second image shows a crossection where the pump is located in the abdominal musculature.  The scout film gives you a good idea how big these pumps are.  They have a reservoir port for percutaneous refilling of the baclofen and they can be interrogated for functioning and changing settings. 

Complications of these can include pump failure, baclofen running empty, tubing kink or breakage, and infection/hematoma, and a cerebrospinal fluid leak at the site of insertion.

Author:  Russell Jones, MD

March 7, 2014

0 Comments

Pediatric back pain (answer)…

Several days ago I presented an early teenage patient with back pain:

ES of spine 1 ES spine 2

This patient has an osteolytic lesion at T11 which was later biopsied and found to be Ewing’s Sarcoma of the spine.  Roughly 10% of Ewing’s Sarcoma will primarily present in the spinal column.  Pediatric spinal column tumors are very rare but should be kept on the differential diagnosis of pediatric back pain.  Unlike adults, pediatric patients rarely present to the ED with the chief complaint of back pain.  Pyelonephritis and acute trauma are the leading pathology but malignancy should be explored if the clinical scenario is worrisome (weight loss, night sweats, neurologic signs, or unrelenting pain over weeks/months, central spinal tenderness). 

For more information on Ewing’s Sarcoma of the spine here is a summary article from Skeletal Radiology:

Ilaslan H, et al.  Primary Ewing’s sarcoma of the vertebral column.  Skeletal Radiol 2004 Sep; 33 (9): 506-13.

Author:  Russell Jones, MD

March 3, 2014

0 Comments

Pediatric back pain…

Early teen presents with back pain for several months…

ES of spine 1

ES spine 2

This thoracic spine series shows a loss of vertebral height at T11 and an indistinct right pedicle of T11.  What could cause this in an early teenager?  There was no history of trauma.

Answer to follow.

Author:  Russell Jones, MD

Follow

Get every new post delivered to your Inbox.

Join 167 other followers