October 14, 2015


Student Corner: Pediatric Non-Accidental Trauma

A 4-week-old girl was brought to the ED with right thigh swelling after reportedly getting caught up in the restraints of her car seat. Lower extremity radiographs revealed a healing right femur fracture, as well as multiple fractures of the left lower extremity. In light of these findings, a complete skeletal survey was performed. Look at the chest radiograph below. Other than the striking number of fractures that you see, what else do you notice about them?

NAT Image 1

The various posterior rib fractures are in different stages of healing. For example, the left 3rd through 5th posterior rib fractures (red, below) appear most acute, while the left 7th-9th ribs (blue) show some degree of healing. The rib fractures on the right side (yellow) show more substantial callous formation (2nd through 9th, and 11th).

NAT Image 2

Unfortunately, these findings strongly suggest that this patient was the victim of non-accidental trauma (NAT). There are many radiographic findings suggestive of NAT, but some of them are more specific than others.

Highly specific findings include:

  • Rib fractures (especially posterior)
  • Metaphyseal lesions – “bucket handle” or “corner” fractures
  • Scapular fractures
  • Spinous process fractures
  • Sternal fractures

Now, let’s take a closer look at the lower extremity fractures that were initially discovered.

NAT Image 3

These are classic metaphyseal fractures, which we just learned were some of the most highly specific findings for NAT. The child has a healing metaphyseal fracture of the right distal femur. There is also a metaphyseal fracture at the right proximal tibia.

NAT Image 4 crop

The left distal femur shows an acute transverse metaphyseal fracture. Metaphyseal fractures are also seen involving the left distal tibia. Finally, notice the periosteal reaction along the shafts of the left tibia and fibula, right lateral distal femur, and right fibula.

It should be noted that it is very important to rule out other potential causes of such fractures, like Vitamin D deficiency or osteogenesis imperfecta, since a diagnosis or even the suggestion of NAT will bring about a wide range of social, economic, and legal consequences.

The images and fracture patterns above are not all-inclusive for NAT as many fractures can occur. It is imperative that physicians utilize their clinical index of suspicion along with radiologic imaging in search of NAT.

What should be included in a typical skeletal survey when NAT is suspected? The American College of Radiology suggests the following protocol:

  • Chest (AP, lateral and bilateral obliques to include the thoracic and upper lumbar spine)
  • Pelvis (AP, to include the mid-lumbar spine)
  • Lumbosacral spine (lateral)
  • Cervical spine (AP and lateral)
  • Skull (Fontal and lateral, oblique view as needed)
  • Humeri (AP)
  • Forearms (AP)
  • Femurs (AP)
  • Lower legs (AP)
  • Hands and Feet (AP)


Images courtesy of Dr. Thomas Sanchez


Jayakumar P, Barry M, Ramachandran M. Orthopaedic aspects of paediatric non-accidental injury. J Bone Joint Surg Br. 2010 Feb;92(2):189-95. doi: 10.1302/0301-620X.92B2.22923. Review. PubMed PMID: 20130307.

Johnson K. Skeletal aspects of non-accidental injury. Endocr Dev. 2009;16:233-45. doi: 10.1159/000223698. Epub 2009 Jun 3. Review. PubMed PMID: 19494670.

Ng CS, Hall CM. Costochondral junction fractures and intra-abdominal trauma in non-accidental injury (child abuse). Pediatr Radiol. 1998 Sep;28(9):671-6. PubMed PMID: 9732490.

Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child. 1993 Jan;147(1):87-92. PubMed PMID: 8418609.

Author:  Mitchell Datlow

Continue reading...

July 7, 2015


Student Corner: Peritonsillar Abscess

Peritonsillar abscess (PTA) is one of the most common head and neck infections that is diagnosed in the emergency department. The common presenting symptoms are a muffled/altered voice, throat pain, fever and odynophagia. A non-contrast CT image of a  particularly severe example of a PTA is shown below.



The next horizontal cut image is below, with red arrows to highlight the abscess.


PTA1 with arrows

One of the more striking aspects of the image is the large degree of airway compression, with the maximum measured diameter of the airway being 2cm. Also, the first image shows that the abscess has two distinct “pockets” that eventually coalesce.


To backtrack, this particular patient initially presented with symptoms of fever, chills, dysphagia, dysphonia and trismus. On examination, there were thin tonsillar exudates, erythema and deviation of the uvula. A diagnosis of peritonsillar abscess was made without imaging and the patient underwent incision and drainage, given antibiotics and discharge. The above images were taken after the patient returned to the ED several days later with continued, worsening symptoms.

The options for imaging of a soft tissue infection of the head and neck include CT and ultrasound. In the ED setting, ultrasound is becoming more and more utilized as the preferred imaging modality. However, this patient received a CT because they failed therapy. CT is superior to ultrasound in differentiation between peritonsillar abscess and other infections of the oral cavity and pharynx. It also allows clinicians to determine the degree of airway compromise. Other indications for CT imaging in suspected peritonsillar abscess include: uncertain diagnosis, obstructed view through physical exam or suspicion of an associated infection such as peritonsillar cellulitis.


Overall, peritonsillar abscess is one of the most common soft tissue infection of the head and neck that is encountered in the emergency department. Most of the time, the diagnosis is clinical. Ultrasound is the preferred imaging modality, but CT is useful in a variety of situations as well.


Powell, J. and Wilson, J.A. (2012), An evidence-based review of peritonsillar abscess. Clinical Otolaryngology, 37: 136–145.
Author:  Jaymin Patel
Continue reading...

July 1, 2015


WWWTP #24 Answer…

Trauma patient came in to the ED:


What’s Wrong With This Picture?

The patient’s chest tube is not inserted far enough.  It is also a bit high residing between ribs 3-4.

Chest tubes have a side port and a distal port for suctioning fluids, air from the pleural space.  There is a radiopaque line seen on the tube that is interrupted at the side port (see magnified image).  In this case the radiograph shows that the side port is subcutaneous and not inserted all the way into the pleural space.  The chest tube needs to be replaced!

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

Continue reading...

June 26, 2015


What’s Wrong With This Picture #24 (WWWTP?)

Trauma patient came in to the ED:


What’s Wrong With This Picture?

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

Continue reading...

May 26, 2015


Anxiety Attack…

This patient presented with the chief complaint of an “anxiety attack.”  They felt short of breath, onset after arguing with another person, and they had a history of panic attacks in the past.  Here’s what we found…

Saddle Embolus 1 Saddle embolus 2 Saddle embolus 3

This is a scary pathology that is on the differential of panic attack:  saddle pulmonary embolus.

“Saddle” refers to a main pulmonary artery involvement.  In the images above you can see a filling defect just as the main pulmonary artery branches off to the right and left sides (see red arrow below).

saddle-embolus-3 (edit)

Large main pulmonary emboli are life threatening diagnoses that can easily progress to sudden death.

History of present illness in this patient screamed panic disorder.  However, we had some clinical clues that altered the direction of the case:  hypoxia to the high 80s, tachycardia, and an EKG with a right axis.  On review of systems the patient said she had had vague calf pain over the last week.  Thus we ended up pursuing CT imaging as opposed to treating her “panic attack” with benzodiazepines…good call!

Author:  Russell Jones, MD

May 19, 2015

1 Comment

Student Corner: Air Everywhere

This time, we have an interesting CXR to examine. There are three distinct places in the image below where air is in places it shouldn’t be. Can you identify them?

sp EGD 1


Need a refresher on how to read a CXR? This post will help you out.

Scroll down further for the answer.


PTX, SubQ, Pneumoperitoneum post EGD

Image Key: Blue arrows–supraclavicular subcutaneous emphysema; Purple arrows–pneumothorax; Red arrows = pneumoperitoneum

Pneumothorax: air in the pleural space

On an upright CXR, a pneumothorax is one of the more easily identifiable pathologies in the thoracic cavity. The presence of air separates the parietal pleura and visceral pleura, resulting in the lung tissue being pushed towards midline. This results in the edge of the lung tissue being easily identifiable (purple arrows). The rest of the cavity is devoid of lung markings.

It is important to note that the size of a pneumothorax can vary greatly. Therefore even if the absence of lung markings isn’t as striking as it is in this picture, the edges of the thoracic cavity should always be closely examined to see if there is any evidence of air. On the other extreme is a tension pneumothorax, which is defined as an expanding pocket of air in the thoracic cavity, which causes half of the lung to completely collapse and shift the mediastinal structures in the contralateral direction.

Pneumoperitoneum: air in the abdominal cavity

The presence of air in the abdominal cavity comes from two major sources: outside the body or the GI tract. Air from outside the body enters into the abdominal cavity through either iatrogenic (surgery, peritoneal dialysis) or traumatic (penetrating wound) routes. Air from the GI tract enters if any segment of the bowel is perforated (most commonly secondary to a duodenal ulcer). On an upright CXR, as is shown above, the air rises to the level of the diaphragm and can be identified.

Even though the subdiaphragmatic air in this picture is clearly evident, CXR’s are not the gold standard diagnostic test for pneumoperitoneum. Abdominal CT scans can pick up much smaller amounts of air that may be difficult to visualize on a plain film.

Subcutaneous Emphysema: air in subcutaneous tissue planes

The image above has distinct areas of radiolucency in the supraclavicular area as a result of air tracking in the subcutaneous tissue, which is defined as subcutaneous emphysema. The area is patchy from the infiltration of air into soft tissues.

Similarly to pneumomediastinum, the air comes from either inside the body (secondary to pneumothorax, pneumomediastinum) or outside the body (penetrating trauma, chest tube insertion site). The air travels along fascial planes between the dermal and muscular layers. Another, more serious, cause is necrotizing fasciitis. In this case, however, it is likely that the air entered into the subcutaneous tissues as a result of trauma, which also resulted in a pneumothorax.

Author: Jaymin Patel

Image Contributor: Katren Tyler, M.D.

April 21, 2015


Rare arm fracture…

Elbow GF1 Elbow GF2 Wrist GF 1 Wrist GF2

This patient presented with arm pain after a fall.  The radiographs obtained showed a distal radius fracture along with a radial head fracture (irregularity and bone fragment seen at the radial head).

I haven’t seen this fracture pattern before.  I’m not sure if it can be classified as an Essex-Lopresti fracture (radial head fracture accompanied by dislocation of the radioulnar joint).  In looking at the radiographs I believe the radioulnar joint is still intact.  However, I’m wondering if the clinical principle of the Essex-Lopresti fracture is maintained:  is there a disruption of the interosseous membrane between the radius and ulna.  This disruption can lead to serious long-term disability including pain, loss of pronation, supination and extension range-of-motion (1).

Has someone out there seen this before?  Any pearls of wisdom regarding this fracture pattern?

Author:  Russell Jones, MD

Imaging Contributor:  Joe Barton, MD



1.  Essex Lopresti Fracture.  Wheelessonline.com.  Accessed 4/2015.

April 9, 2015


Student Corner: CT Evaluation of Appendicitis

Appendicitis is commonly encountered in the ER and is the leading cause of surgical emergency in the abdomen. The initial evaluation for a presentation that is concerning for appendicitis often includes history taking and exam, supplemented by labs. The Alvarado Score is a 10 point rating scale that is widely used as a tool to help decide whether or not a patient presenting with abdominal pain requires CT imaging (although it’s overall clinical usefulness is controversial). It is outlined here by MDCalc. According to the rule, a score of greater than 4 warrants CT evaluation and greater than 7 requires immediate surgical consult.  CT scan is a highly sensitive and specific tool in diagnosing appendicitis, however it comes with radiation, cost, and sometimes IV contrast risks.  In the pediatric patient population radiation from CT scans are not as desirable as the long-term consequences have theoretical potential to be deleterious (long discussion…for another post maybe!).

The purpose of this article is to go over characteristics of appendicitis that can be seen on a CT scan. The use of contrast is a long debated point of contention amongst the emergency medicine community and the usual practice varies between institutions. Medscape has a great rundown of the issue here, which notes that the use of contrast may be more beneficial in circumstances where appendicitis is a relatively less likely diagnosis because the contrast better helps characterize other possibilities.  Contrast studies are also more helpful in the patient not expected to have a large amount of intraperitoneal fat.

As usual, it is important to understand the local anatomy when analyzing radiological images of the abdomen. The image below is an example of an axial cut, non-contrast abdominal CT of a patient who came in with abdominal pain concerning for appendicitis. Try to identify the following structures: vertebrae, psoas major, IVC, iliac arteries, small bowel, colon and appendix.


And below is a labeled version of the same image:

Appendicitis labeled

Key: Blue arrow = bowel gas, ascending colon; Green arrows = small bowel; Purple arrows = L and R Iliac arteries; Yellow arrow = IVC; Red arrow = inflamed appendix

This image contains several signs that indicate that the appendix is inflamed. They include:

  • Diameter greater than 6mm–this usually implies the the appendix has either been twisted or blocked off from the cecum by an appendicolith, which causes inflammation
  • Periappendiceal fat stranding–seen as distinct lines that radiate out from the appendix in the image above, it is caused by inflammation of the appendix causes fluid accumulation around the wall of the appendix which turns the normally hypodense surrounding fat into a hyperdense area; note that the visceral fat around the appendix on the L side of the image looks much different than the visceral fat on the other side of the image
  • Appendiceal wall thickening–normally the wall of the appendix is thin and barely noticeable, but this image shows that the wall is generally thickened and may even be slightly more hyperdense than expected (more below)

Other signs that aid in the diagnosis of appendicitis include:

  • Appendiceal wall enhancement–the wall of the appendix becomes slightly more hyperdense when you compare it to the wall of any other loop of bowel, which is again a product of inflammation; note that this finding is usually more evident on contrast-enhanced CT
  • Abscess–the colon has a large reservoir of commensal bacteria, which can grow and wall off into an abscess if they are trapped in the appendix
  • Appendicolith–a calcified mass that is hyperdense on CT which can be an obstruction between the cecum and the appendix

Overall, CT has a high degree of sensitivity and specificity when used to evaluate the possibility of appendicitis. The clues outlined above, especially when seen together and as a part of a larger clinical picture that fits with appendicitis, are instrumental in confirming the diagnosis.


Ohle R, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD. The Alvarado score for predicting acute appendicitis: a systematic review.BMC Med. 2011 Dec 28;9:139. doi: 10.1186/1741-7015-9-139. Review. PubMed PMID: 22204638; PubMed Central PMCID: PMC3299622.

Reich B, Zalut T, Weiner SG. An international evaluation of ultrasound vs. computed tomography in the diagnosis of appendicitis.Int J Emerg Med. 2011 Oct 29;4:68. doi: 10.1186/1865-1380-4-68. PubMed PMID: 22035447; PubMed Central PMCID: PMC3215954.

March 12, 2015


WWWTP #23 (What’s Wrong With This Picture?) Answer

Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  The Xray showed free air under the diaphragm.

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

Turns out this patient has pneumatosis cystoides intestinalis.  He has a history of this disorder and has had a prior laparoscopy showing multiple cystic structures in the intestinal walls.

Findings on imaging:

1.  Chest Xray:  Concern for free air underneath the diaphragm.  He also has a tracheostomy, pacemaker, scoliosis, and a right lower lung infiltrate.

2.  CT abdomen/pelvis:  The coronal imaging shows multiple cystic structures full of free air in the cecal area.  The cross-sectional imaging above shows a large amount of pneumoperitoneum.

Luckily this patient has a history of pneumatosis cystoides intestinalis.  He has had multiple abdominal CT’s showing similar findings.  Clinically he had no abdominal tenderness.  Keep this rare diagnosis in mind for the patient presenting with free air in the abdomen!  Information about pneumatosis cystoides intestinalis:


Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD

March 5, 2015

1 Comment

WWWTP #23 (What’s Wrong With This Picture?)

Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  What is it?

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

What’s Wrong With This Picture?

Answer to follow.

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD


Get every new post delivered to your Inbox.

Join 236 other followers