Archive | October, 2012

Shoulder pain…

October 31, 2012

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This patient had a fall on his shoulder and had pain, deformity of the shoulder.  Here are his radiographs:

This is a simple radiograph of an anterior glenohumeral dislocation (shoulder dislocation).  One can see the importance of a good Y-view (second image)  or an Axillary view (not seen here).  These alternate views help determine if the shoulder is anteriorly or posteriorly dislocated.  Knowing this will help aid in proper reduction.

Lesson is:  always get two views with radiographs.  (mainly directed at early medical learners, forgive me if you experienced learners just yawned)

Author:  Russell Jones, M.D.

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WWWTP #2

October 25, 2012

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What’s Wrong With This Picture?

Can you guess what is wrong with this picture?  Answer to follow.

ANSWER

Author:  Russell Jones, MD

Radiograph Contributor:  Ali Naqvi, MD

Thanks to Ali for being the first contributor to EMREMS!

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Lisfranc Fracture

October 22, 2012

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The other day I posted radiographs of proximal metatarsal fractures and posed the question:  Is this the dreaded “Lisfranc fracture?”

It turns out that this is a complicated question.  Lets dive into what the heck a “lisfranc fracture” means.

The Lisfranc joint is another name for the tarsometatarsal joint of the foot.  It is named after Jacques Lisfranc (1790-1847) who was a surgeon in Napoleon’s army who basically pioneered amputating toes at the tarsometatarsal joint in order to treat gangrene.  The joint contains 5 metatarsals that articulate with 3 cuneiforms and the cuboid.  It is a complicated structure both radiographically and anatomically with mutliple ligaments and bones.  This poses difficulty in identifying exactly what is mean’t when people discuss the “Lisfranc fracture” or “Lisfranc fracture-dislocation.”

Anytime something has multiple bones it becomes difficult to identify subtle radiographic findings.  And it can be missed!  Subtle Lisfranc injuries can happen and can cause significant morbidity if not treated correctly, usually surgically.  There is a classification of Lisfranc joint injuries posed by Hardcastle et al (1) that is commonly used by our bone brotheren (orthopedics).  I refer you to their article for details.

Radiographically you can have multiple findings from subtle to obvious.  Here are some key points and things to look for:

  1. Always obtain 3 views of the foot:  AP, lateral, and 30 degrees oblique
  2. Weight bearing views can show subtle widening of articulation spaces and point out instability due to lisfranc ligamentous injuries
  3. On the AP view, any diastasis of more than 2mm between the base of the 1st and 2nd metatarsals suggest Lisfranc injury
  4. On the lateral view, the superior border of the base of the first metatarsal should align with the superior border of the medial cuneiform
  5. On the oblique view, the medial border of the fourth metatarsal should align with the medial border of the cuboid
  6. A “fleck” sign on the AP view, or an avulsion off the base of the of the second metatarsal or medial cuneiform is a sign of a Lisfranc ligament* injury
  7. CT and/or MRI have been advantageous in radiographically subtle Lisfranc injuries

*The lisfranc ligament traverses the base of the 2nd metatarsal to the medial cuneiform.

The bottom line is these are highly morbid injuries if not treated correctly (and many times even if treatment is optimized).  Orthopedics will often take the patient for operative fixation in order to anatomically align the joint for best long-term result.

Lets re-visit our radiograph and identify if we are concerned:

Fig. 1:  (AP View) No diastasis of more than 2mm.  Also one can see that the lateral border of the 1st Metatarsal is aligned with the lateral border of the medial cuneiform bone.  The medial border of the second metatarsal is aligned with the medial border of the middle cuneiform bone.  This is good alignment and indicates the Lisfranc ligament extending from the base of the second metatarsal to the medial cuneiform is intact.

Fig. 2:  (Lateral view) The superior borders of the medial cuneiform and the base of the 1st metatarsal align

Fig. 3:  (Oblique view)  The medial border of the base of the 4th metatarsal aligns with the medial border of the cuboid.

If you look at all the criteria above you’ll realize that this gentleman only has non-displaced fractures of the proximal 3rd and 4th metatarsals, no signs consistent with injury to the Lisfranc joint.  Consider weight bearing views or CT scan in this case to fully rule out a Lisfranc joint injury.

For a good radiograph showing Lisfranc fracture-dislocation please refer to reference #2 below, or stay tuned and I’ll try and dig one up!

References

1.  Rijn J, Dorleijn D, Boetes B, Wiersma-Tuinstra S, Moonen S.  Missing the Lisfranc Fracture:  A Case Report and Review of the Literature.  J Foot & Ankle Surg 51: 270-274, 2012.

2.  Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier 2011.  Figure 14-123 Pg. 830.

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PORT placement revisited…

October 20, 2012

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A couple days ago I posted a case of a guy with chest wall pain after PORT placement.  I posed the question:  “With a recent PORT placement, what complications can occur and specifically which problems are we looking for when we order a chest Xray?”

A PORT, or a Port-A-Cath (Smith’s Medical) is a long-term central line placed subcutaneously into a central vein to allow for frequent access.  Usually they are placed for chemotherapy administration, as was the case with the man I saw with the chest Xray shown several days ago.  As with any indwelling device or procedure, there are possible complication:

1. Thrombosis:  PORTs can be associated with venous clots and are a risk factor for SVC (Superior Vena Cava) Syndrome

2.  Infection:  infection of the line can cause life-threatening sepsis

3.  Bleeding:  can occur into the chest cavity as well as hematomas around the catheter.  Can be from subclavian vein or artery

4.  Pneumothorax:  the catheter is placed most-often in the left upper chest wall and, as with other central lines, pneumothorax can occur

5.  Mechanical failure:  breaking of the line or migration of the line can rarely occur

PORT-A-Catheters are generally safe and well tolerated.  It is important to know what you are looking for however if you are assessing them in the postoperative time period.  In our case, the chest Xray was obtained mainly to rule out #4 and #5 above.  There are subtle signs of #2 that can occur on chest Xray (such as multiple septic emboli or signs of heart failure from cardiac valvular infection) but generally line infections are a clinical diagnosis in conjunction with cultures from the line.  #1 is best worked up with a CT of the chest in the right clinical situation.  #3 is clinically rare outside of the immediately post-operative time period but if the man had a large pleural effusion on the side of the PORT this could indicate bleeding from the subclavian vein (or less likely artery).

I’ve included the picture again for your reference with the knowledge that it is normal, no findings suggestive of PORT complications.  Note the proper placement of the distal portion of the catheter in the SVC (red arrow):

The gentleman showed no signs of SVC syndrome and the pain was very reproducible.  It was attributed to post-operative pain and he was discharged in good condition.

If you are wondering, the patient does NOT have free air under the diaphragm.  This is his colon as demonstrated by the haustra visible and can sometimes be confused with free air.  This is referred to as Chilaiditi syndrome and occurs because of a transposition of the colon between the liver and the diaphragm.  His was unchanged from prior and is an incidental, non-clinically significant finding (1).

Author:  Russell Jones, MD

References

1.  Saber AA, Boros MJ.  Chilaiditi’s Syndrome:  what should every surgeon know?  Am Surg.  2005 Mar; 71 (3): 261-3.

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Rugby is a rough sport…

October 16, 2012

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This young woman was playing rugby with “the boys” when she fell on one of the other player’s bent knee.  She has pleuritic chest pain and palpable tenderness along the right chest wall anterior axillary line below the armpit (right about where you’d put a chest tube…hint…hint).

This case demonstrates the power of knowing what you are looking for.  As you probably noticed she has a small, subtle pneumothorax best seen between ribs 3 and 4:

Its always a good idea to take the time when you are ordering radiology studies to help out your radiology friends and describe the area of concern and what you are looking for.  This can help them identify subtle findings such as this small pneumothorax.

The patient was treated with supportive care, observed over night, and discharged the next day after a repeat chest xray showing no significant progression.

Author:  Russell Jones, MD

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15 yo male twisted his knee…

October 11, 2012

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The other day I was working in pediatrics and a 15 year-old male came in from his Friday night high-school football game with knee pain.  He is a running back; he twisted his knee when he was tackled and has diffuse knee pain with a slight effusion on exam.  Here is his lateral x-ray:

Fig. 1:  Lateral knee x-ray

Can you identify the abnormality?  This is a hard one…

The patient demonstrates a “deep lateral femoral notch sign” and a small effusion.

A what?  This was a radiology interpretation which I missed entirely (and I would guess many ED physicians would as well).  The lateral femoral notch sign is an abnormally deep depression of the lateral condylopatellar sulcus (See the arrow in Fig. 2).  On the lateral projection the lateral condylopatellar sulcus (aka the lateral femoral notch) is normally a shallow groove in the middle of the femoral condyle.  An unusually deep lateral femoral notch is an indirect sign of an ACL tear (1).

Fig. 2:  Arrow indicates the lateral condylopatellar sulcus (aka lateral femoral notch)

The most common mechanism of ACL tear is rotation and valgus stress.  This causes the posteriolateral tibial plateau to impact the anteriolateral femoral condyle and can cause a impaction at the site of the lateral femoral notch.  Thus…the “Lateral Femoral Notch Sign.”

To measure the depth of the lateral femoral notch draw a tangent line across the sulcus on the anterior surface of the lateral femoral condyle.  Measure the depth with a perpendicular line to the deepest portion.  Normal depth is around 1mm.  If the depth is >2.0mm this is highly suggestive of an ACL injury.

Luckily I had suspected an ACL tear from the beginning and treated accordingly…

References

1.  Pao DG.  The Lateral Femoral Notch Sign.  Radiology 2001; 219: 800-801.

Author:  Russell Jones, M.D.

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Chest wall pain…

October 9, 2012

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This gentleman presented to the ED today with chest wall pain anterior L sided.  Pertinent history included a PORT placement 1 week ago.  Here’s his Chest Xray:

This is an example of a normal PORT (portacath) placement.  With a recent PORT placement, what complications can occur and specifically which problems are we looking for when we order a chest Xray?

To be continued later…

Comments are appreciated if appropriate!

Author:  Russell Jones, M.D.

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Foot pain after stepping into a pothole

October 7, 2012

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This gentleman is presented today with pain in his foot after stepping wrong into a pothole yesterday.  He had significant swelling over the dorsal foot and tenderness to palpation near the site of the xray findings.  Can you spot the problem?

The xray shows non-displaced fractures of the proximal third and fourth metatarsals.

The question is…does this patient have the dreaded “Lisfranc fracture?”

Discussion to follow, comments are appreciated.

Author:  Russell Jones M.D.

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48-year-old male with R flank pain

October 1, 2012

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Chief Complaint:  “My right side hurts”

On a busy night in the ED you encounter a 48-year-old male with right flank pain.  Onset was sudden, severe, 10/10, waxing and waning pain.  You obtain a urine dip which shows 3+ blood.

Here is his non-contrast CT abdomen/pelvis:

What is the diagnosis?

Answer:  Ureterolithiasis

This man has a 0.6cm stone in his ureter.  The CT scan shows two slices, one visualizing a hyper dense spherical structure in the ureter and the other demonstrating hydronephrosis with perinephric stranding.  This is considered an obstructing stone.

Kidney stone causing acute pain is one of the most common, most satisfying ED diagnoses.  These patients usually are in significant pain, sometimes sweating bullets from their pain!  And we can and usually make them better.  In fact, IV ketorolac is one of the most efficacious medicines available for stones.  I personally love the kidney stone…I feel like I can make a difference with this diagnosis.

Emergency Medicine Practice (one of my favorite CME publications) in July 2011 provided a great review of renal calculi. In particular it quoted an an article which found a 98.3% sensitivity and a 100% specificity of ultrasound in patients suspected of  having renal colic.  CT had a sensitivity and specificity approaching 100%.  The article also discusses admission criteria, special cases such as pregnancy and pediatrics, as well as recommendations for those patients sent home from the ED.  I will refer you to the article for details.

References

1.  Carter MR, Green BR.  Renal Calculi:  Emergency Department Diagnosis and Treatment.  Emergency Medicine Practice; 13 (7), 2011.

Author:  Russell Jones, M.D.

Imaging Study:  CT abdomen/pelvis without contrast

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Why can’t you inject Heroin into your gluteus musculature?

October 1, 2012

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Because it can easily end up in abscesses:

Notice the two rim-enhancing lesions with center hypoattenuation consistent with abscesses on both gluteal areas.  He also has stranding surrounding the area of concern.  This CT image is near the distal sacrum of the pelvis.

He admitted to injecting “tar heroin” intramuscularly in his bilateral gluteal areas.  Last injection was over three days ago and he had a fever, leukocytosis.  With the stranding, rim enhancement, and the clinical picture these were considered abscesses rather than simple fluid of the injected heroin.  This patient would be at risk for MRSA (Methicillin-resistant Staph. Aureus) and was covered with IV clindamycin and admitted to the surgical service for further evaluation and possible operating room intervention.

Author:  Russell Jones, M.D.

Imaging Study:  CT Pelvis with IV Contrast

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