Archive | XR RSS feed for this archive

Central line complication…

April 14, 2014

0 Comments

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...

Reasons not to try relocation of hips…

April 7, 2014

0 Comments

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...

Multiple masses chest..

April 3, 2014

0 Comments

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...

Bad orthopedics…

March 19, 2014

0 Comments

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

Continue reading...

Pediatric back pain (answer)…

March 7, 2014

0 Comments

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

Continue reading...

Pediatric back pain…

March 3, 2014

0 Comments

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

Continue reading...

Heart in the Heart…Happy Valentine’s Day

February 14, 2014

0 Comments

This patient had a transvenous pacemaker placed for severe bradycardia:

Heart in heart

 

This patient has a transvenous pacing wire which decided to loop around the right side of the heart.  It was working though!  Happy Valentine’s Day.

Image contributor:  James Chenoweth, MD

Author:  Russell Jones, MD

Continue reading...

Classic Xray…

February 3, 2014

0 Comments

This patient presents with a peritoneal abdomen on exam:

Free air 1 Free air 2 

This is a great abdominal series showing free peritoneal air.  This is a sign of gastric, bowel, or colonic perforation and is a surgical emergency. 

The abdominal series has limited utility in the ED due to poor sensitivity and specificity for most intraabdominal pathology.  However, in a patient with a peritoneal abdomen it is a quick and cost-effective means of screening for free air.  This patient was emergently taken to the operating room for exploratory laparotomy. 

Author:  Russell Jones, MD

Image Contributor:  Ali Naqvi, MD

Continue reading...

Stabbed in the chest…

January 29, 2014

0 Comments

This patient was stabbed in the chest multiple times.  Markers showing the external stab wounds to the lateral chest wall on the right side:

HemoPTX stabbed

This is a classic trauma chest xray with a hemopneumothorax on the right side.  This patient has a great indication for a large-bore chest tube!  Not only to reexpand his lung but to monitor hemothorax output and need for emergent thoracotomy to evaluate the source of bleeding.  Trauma recommendations from the Journal of Trauma in 2010 concerning hemothorax include:

1.  Patient physiology should be the primary indication for surgical intervention rather than absolute numbers of initial or persistent {chest tube} output (Level I recommendation)

2.  1500 ml via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration (Level II recommendation)

3.  All hemothoracies, regardless of size, should be considered for drainage (Level III recommendation)

Please see the EAST Trauma Guidelines for further details:

Mowery NT, et. al.  Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax.  J Trauma 2011; 70 (2): 2011. 

Author:  Russell Jones, MD

Continue reading...

Lumbar mets and fracture…

December 27, 2013

0 Comments

Elderly male came in with acute onset pain in lumbar spine.  He indicentally has had weight loss over the past 6 months, about 40 lbs:

Path Fx L Spine 2 Path Fx L spine

This patient has a pathologic compression fracture of L1 vertebral body.  Also demonstrated are sclerotic lesions in L4 without a fracture. 

What is the most likely primary lesion?

Author:  Russell Jones, MD

Continue reading...
Follow

Get every new post delivered to your Inbox.

Join 167 other followers