Archive | December, 2012

WWWTP#3 Answer

December 22, 2012


What’s Wrong With This Picture #3 (Answer):

This chest Xray was posted last week:


This patient came in with a known disorder of achalasia requiring frequent botox injections at his GE junction, but missed his last appointment and was having difficulty swallowing. You can clearly see the outline of the very large proximal esophagus coursing behind the mediastinum. The primary screening method for achalasia is a barium swallow study, usually followed by manometry to confirm the diagnosis. This patient had an endoscopy by the GI team in the ED and had a large food bolus removed with subsequent injection of botox the next day with good symptom resolution.
Author:  Nate Parker, MD
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Patella Fracture

December 20, 2012

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I saw a nice elderly female with anterior knee pain after tripping on the curb and falling to her knees. Here is her knee X-ray:

Patella fx 3Patella fx 2Patella fx 1

The AP and lateral knee radiographs demonstrate a non-displaced transverse patellar fracture. Sometimes these can be difficult to see on AP and lateral films. Another view that can sometimes be helpful is the “sunrise” view of the patella.

Most patella fractures are managed non-operatively.  If, however, the patella fragments are displaced more than 3-4 mm on xray there is a higher chance of retinacula compromise requiring operative repair (1).  Clinically if the patient cannot maintain their knee in extension against gravity this is concerning for retinacular tear. 

This patient has a high chance, despite age, of having a good outcome with non-operative management (she had intact extensor mechanism of the knee). 


1.  Wheeless’ Textbook of Orthopedics.

Author:  Russell Jones, MD

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Interesting Websites

December 18, 2012


As we all are probably aware the use of radiation in the emergency department has increased over the past two decades.

The UC Davis EM Residency had our weekly lecture series today and we had a lecture about decreasing ionized radiation. The lecturer pointed out some interesting websites dedicated to education on this topic:

If you have a chance go check out these websites. I’ll leave it up to you to formulate opinions on accuracy of the education they provide. I found it fun to predict my risk of cancer after a “pan scan” on Yes, I admit the “fun” statement makes me at risk of being labeled “nerdy” but oh well.

Author: Russell Jones, MD

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Blunt Aortic Injury (BAI)

December 17, 2012


One of my colleagues had a patient come in after a high-speed motor vehicle collision (MVC) and the patient turned out to have a blunt aortic injury (BAI).  Luckily she saved the images for EMREMS:

This first image is a portable AP Chest Xray.  There are multiple findings:

1.  The ETT tube is slightly high, this was corrected (see Post Intubation Eval)

2.  Chest tube is inserted in the left side and the patient has subcutaneous emphysema.  The chest tube could have been put in further but seems to be working.

3.  Notice the loss of normal contour of the aortic knob (aka “indistinct aortic knob”).

4.  The trachea is displaced to the patient’s right

5.  The upper mediastinum seems a little wide although not drastically.

6.  There is loss of the aortopulmonary window (AP window)

For comparison I have a normal AP Chest Xray and have arrows pointing to the normal AP window and aortic knob:

The patient’s Chest Xray is worrisome for traumatic aortic dissection.  Here is the patient’s Chest CT which confirms the diagnosis:

In the first image one can see a rough inner surface of the aorta indicating intimal disruption and hematoma.  A dissection flap can be seen in the second image.  Hematoma can be seen on both images surrounding the aorta and tracking in the mediastinum.

What are some other signs on Chest Xray that would get you worried about BAI? (Comments are encouraged)

Stay tuned in the future for a “Radiology Rules” 3X5 card with Chest Xray signs of BAI.

Author:  Russell Jones, MD

Image contributor:  Kendra Grether-Jones, MD

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Left Lower Quadrant Pain

December 15, 2012

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Here is an interesting CT abdomen in a middle-aged patient with 10 days of left lower quadrant pain and fevers:

This patient has an 8cm abscess from perforated diverticulitis.

In the center of the image you can see a large air and fluid filled cavity with surrounding fat stranding.  This is consistent with an intraperitoneal abscess.  In middle-aged and elderly patients diverticulitis is a very common cause of intraabdominal abscess.  Other causes include perforated appendicitis, post-surgical infection, inflammatory bowel disease, surgical site anastomotic leak, perforated peptic ulcer, gangrenous cholecystitis, mesenteric ischemia with perforation, and pancreatic abscess.

Abscesses on CT have several classic features:

1.  Heterogeneous contents including various densities of fluid and debris with gas formation

2.  Rim enhancement with IV contrast due to high blood flow to the structure

3.  Surrounding inflammation seen as fat stranding

Radiology usually likes oral contrast if you suspect an intraabominal abscess because it helps distinguish abscess cavities from surrounding loops of bowel.  If you are studying abscesses in soft tissues or organs such as the liver, oral contrast is unnecessary.

Author:  Russell Jones, MD

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December 12, 2012


What’s wrong with this picture (WWWTP) #3?


There is a not-so-subtle abnormality with this chest XR.  What is it?

Author:  Russell Jones, MD

Image Contributor:  Nate Parker, MD

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Answer: Post-intubation Eval

December 6, 2012


This radiograph was posted yesterday and I posed the question:  Is the endotracheal tube (ETT) in good position?

normal-intubation2 edited 1

This ETT is in great position on the AP chest radiograph.  Every ETT should have a radiopaque line extending to the tip in order to identify the tube length.  Ideally the tip of the ETT (arrow) should be midway between the thoracic inlet (top dotted line) and the carina (bottom dotted line).  Some pointers:

  • The thoracic inlet on chest XR is roughly at the level of the clavicles.  Anatomically it is the superior portion of the manubrium anteriorly.  This is the level of the subglottis area and upper trachea.
  • The carina is usually located around T5-T7 and is usually easily identified on chest XR.  If you have difficulty draw a line from the inferior main bronchi and they intersect at the carina.
  • The ETT in a normal adult can advance and retract up to 2cm with neck flexion and extension.  Therefore it is recommended that the ETT is at least 2cm from the carina and 2cm from the thoracic inlet.
  • Most commonly the ETT will be placed in the right mainstem bronchus if placed improperly in the airway.
  • Signs that the ETT is in the esophagus include a dilated, air filled stomach and esophagus.  And…oh yeah…the patient may not be doing well.
  • With digital imaging it is easy to play with the intensity if you cannot identify the tube or carina.  Also, inverting the image to a “negative” image can sometimes help.

Author:  Russell Jones, MD

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Post intubation eval

December 5, 2012


For all those beginning their career here’s a post-intubation chest XR.  Can you identify the end of the endotracheal tube?  Is it in good position?

Answer to follow.

Author:  Russell Jones, MD

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December 3, 2012


Here’s a good reason not to put nails in your mouth while doing construction at home:

The patient accidentally swallowed the nails while trying to hammer one in and you can see them on the radiograph above.  The good news is they weren’t in the airway which can cause much more acute life threatening injuries.  Sharp objects such as this in the GI tract usually warrant a GI or surgical consult because of the high risk of perforation.

Author:  Russell Jones, MD

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