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Maisonneuve Fx…

August 14, 2014

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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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What are these devices? Answer…

July 31, 2014

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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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What are these devices?

July 28, 2014

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

IABP 2

 

Answer to follow!

Author:  Russell Jones, MD

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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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