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Not your ordinary arm fracture…

July 21, 2014

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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

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WWWTP #17 Answer…

June 30, 2014

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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

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

June 23, 2014

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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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Aortic dissection…

June 16, 2014

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This patient presented with chest pain radiating to the back:

AD CXR 1

 

The patient’s initial chest X-ray shows a widened mediastinum and an indistinct aortopulmonary window.  CT showed:

AD CT 1 AD CT 2 AD CT 3

This patient has an aortic dissection.  There are two different classification systems for aortic dissection:  Stanford and DeBakey (1).

Stanford Criteria:

  • Type A:  The dissection flap involves the ascending aorta
  • Type B:  The dissection commences distal to the left sub-clavian artery

DeBakey Criteria

  • Type I: The dissection flap involves the ascending aorta and descending aorta
  • Type II:  The dissection flap involves the ascending aorta only
  • Type III:  The dissection flap involves the descending aorta only

This is a Stanford Type A and a Debakey Type I because it involves the ascending aortic arch all the way to the iliac bifurcation.

What is important to remember (besides the number for a cardiothoracic surgeon)?  If the flap involves the ascending aorta these are usually managed operatively. Descending dissections are many times managed medically (1).

Besides rupture, the main problem with aortic dissection is perfusion to various organs.  Virtually every solid organ can be affected depending on the spacial characteristics of the dissection flap.  In this case the last image clearly shows that the right kidney is not perfused, indicating that the dissection flap has occluded the right renal artery.  The kidneys and bowel are the most common organs to develop ischemia.

Author:  Russell Jones, MD

Image Contributor:  Jay Williams, MD

References

  1. Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier, 2011.
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More colonic dilitation…

June 9, 2014

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This patient presented with abdominal pain, nausea, vomiting, and distention:

Volvulus 1 Volvulus 2 Cecal Volvulus 2 Cecal Volvulus

These films and CT show colonic dilatation similar to last week (sigmoid volvulus).  However, in contrast to last week, this is a cecal volvulus.  In this CT there is marked dilatation of the cecum with a central location in the abdomen.  Usually a cecal volvulus will have visible haustra as opposed to a sigmoid volvulus in which colonic haustra will not be present.  Sometimes, as in the above images, the haustra are difficult to see.  This also looks like it may be a more rare form of cecal volvulus called a cecal bascule.  For more information I will defer to our radiology colleagues at Radiopaedia:

Caecal Volvulus

For all you radiologists out there, do you think this is consistent with a cecal bascule?

Why note the difference between cecal and sigmoid volvulus?  The treatment can be drastically different.  Sigmoid volvuli are many times amenable to acute management non-operatively (sigmoidoscopy) whereas cecal volvuli usually require open laparotomy and have a higher frequency of partial colectomy.

Author:  Russell Jones, MD

References

1.   Gaillard F et al.  Caecal Volvulus. http://radiopaedia.org/articles/caecal_volvulus

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Colonic dilitation…

June 2, 2014

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This is a 50 year old male who presented with nausea, vomiting, and abdominal distention.  His initial plain film showed:

CV 1

A CT scan was ordered for given suspicion for colonic obstruction:

CV Scout 1 CT Swirl 1

 

The CT scout film clinches the diagnosis with the classic “Coffee Bean” sign consistent with a sigmoid volvulus. The CT scan not only shows the massively dilated colon but demonstrates the associated “swirl” sign of the mesentery (arrow). He underwent a flexible sigmoidoscopy with partial reduction of his volvulus.  He then underwent a colectomy for definitive management of his volvulus.  He had a return of bowel function and discharged a week later.

Author:  John Ray, MD

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Antibiotic beads in a knee…

May 26, 2014

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This patient had a history of osteomyelitis of his distal femur and a septic knee.  This caused significant destruction requiring knee replacement and antibiotic bead placement (the radio opaque spherical objects).  He re-presented several weeks later with fever and knee pain:

Antibiotic beads 1

Antibiotic beads 2

There are multiple issues with these radiographs that are chronic.  It was helpful clinically to have a comparison which showed that the hardware was all intact and unchanged.  The ACUTE finding on this radiograph is radiolucency under the patella (as well as proximal to the patella) concerning for gas.  This patient was taken to the operating room for a septic joint (again).

Author:  Russell Jones, MD

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WWWTP #16 Answer…

May 22, 2014

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Several days ago I asked What’s Wrong With This Picture (WWWTP #16):

Elbow fx 3Elbow fx 2Elbow fx 1

Here’s what radiology thought:

1.  There is a fracture of the lateral epicondyle with displacement.

2.  There is subluxation of the capitellum anteriorly.

3.  There is a minimally displaced fracture of the olecranon process.

4.  There is a large amount of soft tissue swelling adjacent to the elbow, most pronounced laterally.

5.  Exam is somewhat limited due to lack of true lateral radiograph.

 

#1 is fairly easily identified on all 3 radiographs.  #2 is readily apparent if you apply the anterior humeral line to the radiograph, see link below for further details.  #3 can be best identified by the lucent line on the latter two radiographs.  #4 is apparent also on the second two radiographs.  #5 is a true statement, it is not a great lateral radiograph.  However, can you imagine the difficulty the radiology tech had trying to get anatomic landmarks when it is this swollen?

Hopefully you got all the findings!

Here is a brief review of the anterior humeral line of the elbow from radiopaedia.org:

Anterior Humeral Line

Author:  Russell Jones, MD

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Multifocal opacities…

May 12, 2014

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A patient presented to the ED with flu-like symptoms in the height of flu season:

multifocal opacities

Chest CT:

Multifocal opacities CT 2 Multifocal opacities CT

The CT demonstrates multifocal opacities with some cavitation on the larger lesions.  There seems to be a peripheral and lower-lobe predominence.  This could represent atypical pneumonia (legionella, mycoplasma, chlamydia), fungal pneumonia (cocciodomycosis, histoplasmosis, aspergillosis), miliary tuberculosis, metastatic lesions or carcinomatosis, septic emboli, or viral pneumonia.

After a significant inpatient workup the final diagnosis was Human Metapneumovirus.  All others were ruled out and viral testing revealed this culprit.

Image contributors:  David Barnes, MD and Julie Phan, MD

Author:  Russell Jones, MD

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Interesting osteomyelitis…

May 6, 2014

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This patient presented with multiple skin lesions with an ulcerative mass to his thumb…

OM hand

This patient had an ulcerative, indurated lesion to the distal thumb which can be seen on the above radiograph.  The radiograph also demonstrates periostitis and osseous erosion of the distal thumb and metacarpal joint of the thumb.  There are subtle periosteal changes to the third phalanx as well.

It turns out this patient has sporothrix schenkii osteomyelitis.

Author:  Russell Jones, MD

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