Archive | November, 2012

Pelvic foreign body

November 27, 2012

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A 35 year-old female came into the ED with diarrhea for several weeks.  She had a story highly suspicious of c.diff and we sent her for an acute abdominal series to evaluate for megacolon, other findings.  Here is her supine view:

As far as megacolon this is negative.  However, the foreign body in her left pelvis region was interesting and we initially had no idea what to make of it.  When in doubt, go ask the patient…

She has an Essure® device implanted into her left fallopian tube.  Not only that, she had an ectopic pregnancy in her past on the right side with a right sided salpingectomy (thus no bilateral Essure®). 

An Essure® device is a small, flexible implant non-surgically placed in the fallopian tube in place of a tubal ligation. 

Didn’t explain her diarrhea though.  She had c.diff.

Author:  Russell Jones, MD.

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Orbital Cellulitis

November 21, 2012

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This is a facial CT from a patient seen the other day in pediatrics with orbital cellulitis:

This is an interesting CT for several reasons:

Image #1 shows all ethmoid sinuses are opacified with destruction of the anterolateral wall of the ethmoid sinus, the cause of the orbital cellulitis

Image #2 shows a large abscess formation in the superior portion of the orbit causing…

Image #3  a significant proptosis of the left eye

Image #4 shows a frontal view further identifying the abscess.

Clinically this patient had a very proptotic eye, angry red and swollen periorbital area to the point that it was difficult to get an ocular view. 

Author:  Russell Jones, MD

Image contributor:  Ali Naqvi, MD

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Holy Cardiomegally Batman…

November 18, 2012

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Just saw this guy, he presented with severe dyspnea:

 

 

This is severe cardiomegally!  He looked very bad, had HTN in the 220/120 range, and sounded wet even though his xray doesn’t appear particularly full of pulmonary edema.  IT IS CRUCIAL THAT YOU RULE OUT CARDIAC TAMPANODE WITH THIS XRAY!

Turns out this guy wasn’t that interesting.  Bedside ultrasound didn’t show an effusion.  He had a severely dilated cardiomyopathy and once we got his blood pressure under control with nitrates he improved dramatically. 

Author:  Russell Jones, MD

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WWWTP#2 Answer

November 15, 2012

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Answer to the What’s Wrong With This Picture (WWWTP) #2 posted in late October:

Fracture of the triquetrum.  A small avulsion-type fracture can be seen best on the lateral projection:

The triquetrum is 2nd most commonly fractured carpal bone. Mechanism of injury is typically hyperextension or hyperflexion of an ulnarly deviated wrist. >90% of these are avulsion or “chip” fractures, with the remaining minority being midbody fractures. Midbody fractures have a greater association with nonunion and perilunate dislocation and generally require more aggressive management. Dorsal avulsion fractures are most common and are often missed on A/P films, and are usually best visualized on lateral views. There are routinely managed nonoperatively with immobilization for 3-6 weeks. Avulsion fractures that remain symptomatic despite appropriate management should raise concern for concomitant injury to the triangular fibrocartilage complex or ligament disruption.

Author:  Ali Naqvi, MD

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FOOSH!

November 12, 2012

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Another eponym fracture, courtesy of John Neuffer, MD at WVU.  Dr. Neuffer saw a patient with a fall on an outstretched hand (FOOSH) and this was the result:

This is an example of a Colles Fracture.  Colles fracture is a distal radius fracture with dorsal displacement of the distal fracture fragment and wrist.  FOOSH is a popular mechanism of this injury as well as any other mechanism that causes an axial load on the distal wrist with extension of the hand.

There are two other interesting parts of this image:  1.  There is an ulnar styloid fracture  2.  The pisiform is dislocated.

Ulnar styloid fractures are very common with FOOSH mechanism and in conjunction with distal radius fractures.  Common xray findings with a Colles fracture include (1):

  • Transverse radius fracture
  • Dorsal displacement and angulation
  • Radial angulation of the wrist
  • Location 1 inch proximal to the radiocarpal joint
  • Radial shortening
  • Ulnar styloid fracture
  • Salter-Harris fractures in children

Pisiform dislocation is rare.  On the lateral view above you can see the pisiform is displaced off the triquetral bone (its only articulation).

This is what it should look like:

Pnormalpisform.png

(Above is a link to Wikipedia.  James Heilman, MD has a post about the pisiform with a great lateral radiograph demonstrating a normal positioned pisiform.  Go check it out!)

Author:  Russell Jones, MD

Image Contributor:  John Neuffer, MD

Thanks to Dr. Neuffer at WVU for the image as well as pointing out a good EM blog for me to follow:  EMchatter.com.  Keep up the good work and send me more good images!

References

1.  Broder JS.  “Imaging the Extremities.” In: Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier Saunders, 2011.

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Gun Shot Wound (GSW) to the head..

November 9, 2012

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Working an overnight the other day and had an interesting GSW present to the ED.  This man was reportedly found in the driver’s seat of a car very near the entrance to the ED parking lot.  GCS was 3, he was intubated shortly after arrival.  He had a large stellate laceration on top of his head just left of midline.  It extended from about where you’d expect the coronal suture line to be, all the way to the poterior-most portion of his occiput (kinda like the bullet skipped off the top of his head and made a big laceration).   His GCS was low because of this:

This is a good example of an acute subdural hematoma from penetrating trauma.  It appears the bullet damaged many of the bridging vessels and acute blood can be seen as a white layering density on the right side of the image.  Remember, acute blood is hyperintense with higher Hounsfield Units (HU) similar to bone.  As it matures it will eventually become darker and darker until it is less intense than brain tissue.

This CT is also a good example of mass effect.  Mass effect is a term used most often in head imaging because of the limited volume of the closed cranial vault.  If an extraneous volume is added to the vault it will compress or displace brain tissue thus causing “mass effect.”  Mass effect is most often caused by blood, tumors, edema, or obstruction of CSF flow (1).  The best way to assess for mass effect is to look at the ventricles, the falx cerebri, and the overall symmetry of the brain.  In the example above one can see the lateral ventricles are displaced to the left of the image (patient’s right side) and the falx bends in that direction because of the subdural blood.  Clinically this causes decreased mentation, signs of herniation, and eventual respiratory arrest due to compression of the respiratory centers of the brainstem.

How do we know this is subdural blood not epidural?  Remember, subdural blood crosses suture lines, epidural blood does not.  Also, subdural blood tends to easily distribute throughout the contours of the brain (causing a convex shaped collection) whereas epidural blood forms a lenticular shaped collection.  Subdural blood is in the space between the dura and the arachnoid while epidural blood is between the skull and the dura.  The other significant difference is that subdural blood is usually venous (sometimes can be arterial) and epidural blood is usually arterial (classically from the middle meningeal artery).  Arterial and venous blood cannot be differentiated on imaging but it may be distinguishable by the timing of the patient’s clinical symptoms after trauma.

The second image has been switched to bone windows and one can appreciate the bony damage from the bullet.

There were two predominant theories about how the patient got to the ED parking lot:  1.  He was shot and had time to drive to the ED while the blood collected in the subdural space.  2.  He was shot in the ED parking lot.  All of us reassured ourselves that is was definitely number 1, not the latter!

References:

1.  Broder JS, Preston R.  “Imaging the Head and Brain.” In: Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier Saunders, 2011.

Author:  Russell Jones, MD

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Radiology Rules: Lisfranc Fractures

November 7, 2012

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A little while back I discussed Lisfranc fractures of the foot.  Here is an image depicting a fracture-dislocation through the Lisfranc joint:

This one is not subtle!  You can see that the bases of metatarsals 1-5 are laterally dislocated.  Remember, the Lisfranc joint involves articulation between metatarsals and tarsus (navicular, cuboid, and three cuneiform bones).  A Lisfranc fracture occurs when one or more of the metatarsals are dislocated from the tarsus.

As a reminder of the Lisfranc radiology findings here is a Word® document reminding us of the “Radiology Rules.”  It is in 3X5 card format you can print front and back and have a convenient reminder if you want to carry it with you on your clinical shifts.  That way hopefully we won’t miss the subtle ones…

Radiology Rule Lisfranc

Author:  Russell Jones, MD

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Football injury…

November 4, 2012

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I was working peds last night and an 8-year-old male came in with elbow pain after falling on an outstretched hand while playing football.  Another player fell on his elbow at the same time.  He had an obvious deformity and his elbow film is classic for an eponym fracture:

This is a Monteggia fracture-dislocation.  It involves a fracture of the proximal ulna and dislocation of the radial head.

Giovanni Monteggia (1814) originally described this fracture pattern.  It is usually associated with a direct blow or a hyperpronation, extension mechanism.  In this radiograph the radial head dislocation is obvious, however sometimes it can be subtle and missed.  Always draw a line through the radial head and make sure it intersects the capitellum on both the AP and lateral views (radiocapitellar line).  Here is an example of a normal radiocapitellar line:

 

Author:  Russell Jones, MD

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Dyspnea

November 1, 2012

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A 62-year-old male presented with dyspnea and a portable upright chest X-ray looked like this:

The radiograph shows a complete opacification of the right hemithorax with tracheal deviation in that direction.  The differential diagnosis for this radiograph includes:

1.  Large pleural effusion

2.  Hemothorax (especially in trauma and known malignancy)

3.  Pneumonia involving all right lobes

4.  Empyema

5.  Obstructing mainstem bronchus (mass or foreign body)

6.  Massive aspiration

If this patient is in extremis bedside ultrasound would be very beneficial to see if this is a drainable effusion.  It turns out this patient was not in severe respiratory distress, bedside ultrasound was not consistent with pleural effusion, and the patient went to CT scan.  Chest CT showed a completely obstructed mainstem bronchus and fluid-filled lung parenchyma with associated atelectasis.  There was no pleural effusion.

One of the interesting points of the radiograph is the tracheal deviation.  This usually indicates a volume loss on the side of the deviation or a volume gain on the opposite side.  Since there is no identifiable volume gain (pneumothorax) on the left side this indicates a volume loss in the form of atelectasis on the right side.  This is a good example of why one should be wary of immediately performing therapeutic thoracentesis with this X-ray.  Use your bedside ultrasound if you have it!

Author:  Russell Jones, MD

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