Archive | June, 2013

Worst distal radius ever…

June 30, 2013

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Not much to talk about other than this is one of the worst distal radius fractures I’ve ever seen:

Worst DR fx everWorst DR fx ever 2

Needless to say, this ended up in the operating room.  Yes, it was open.  You can also see dislocation of the carpus away from the radius and ulna as well as multiple carpal bone fractures. This was very close to a full hand amputation at the wrist!

Author:  Russell Jones, MD

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What is bronchiectasis…

June 26, 2013

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This patient presented with dyspnea and had “bronchiectasis:”

BronchiectasisBronchiectasis CXR

Bronchiectasis is a disease process in which there is localized, irreversible dilitation of the bronchial tree.  The dilitation occurs because of destruction of the normal musculature and elastic connective tissue surrounding the bronchi.  Clinically it presents as an obstructive respiratory picture similar to asthma and COPD.  The most common causes are cystic fibrosis and multiple infectious organisms (bacterial, aspergillosis, tuberculosis, histoplasmosis).  The dilated bronchi easily collapse causing air and mucus trapping, which in turn can lead to frequent respiratory infections.

Radiographically, CT scan is the diagnostic modality of choice if bronchiectasis is suspected.  Classically on plain radiograph “tram-tracking” occurs (parallel thickening of the bronchial walls) as well as cystic changes.  CT scan can further deliniate bronchiectasis by showing “tree-in-bud” abnormalities as well as multiple other signs.  For more in-depth information on radiographic findings please refer to Radiopaedia.org:

Bronchiectasis

Author:  Russell Jones, MD

References

1.   Sandhyala A, Gaillard F, et al.  Bronchiectasis.  Radiopaedia.org.  http://radiopaedia.org/articles/bronchiectasis.  Accessed 6/12/13

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Another reason not to punch things…

June 22, 2013

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A patient came in the other day after punching a wall.  He had an injury pattern I had never seen before:

mcp DISLOCATIONMCP disloc

These PA and Lateral images of the hand show dorsal dislocation of the index and middle metacarpals at the carpometacarpal joint.  You can see the proximal ends of the index and middle metacarpals posterior to the trapezium, trapezoid, and capitate bones (in order from the base of the thumb toward the ulnar side of the wrist).  This is a very rare injury and may need operative fixation (1).

Image Contributor:  Aaron Bair, MD

Author:  Russell Jones, MD

References

1.  Carpometacarpal fracture dislocation.  Wheeless’ Textbook of Orthopaedics.  http://www.wheelessonline.com/ortho/carpometacarpal_fracture_dislocation.  Accessed 6/12/13.

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Has anyone seen my tooth?

June 18, 2013

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9-year-old child presented to the ED with lip swelling after a fall.  On exam part of the patient’s incisor tooth could not be found and there was significant anterior upper lip swelling associated with a laceration to the buccal mucosa of the inner lip.  Xray revealed:

Fractured tooth

The fractured portion of the tooth can be seen lodged in the anterior lip!  The fragment was then removed and the patient was referred to dentistry. 

Author:  Russell Jones, MD

Image Contributor:  Kendra Grether-Jones, MD

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Bosniak classification for renal cysts…

June 14, 2013

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Had a gentleman come in for trauma to the abdomen and his incidental finding on CT abdomen was a “Bosniak Type-2 renal cyst”:

Bosniak 2 cyst

On the right kidney you can see a hypoattenuated lesion, less than 3 cm. 

Kidney cysts are one of the most common incidental findings in radiology.  There exhists a Bosniak classification system to help with further workup.  A summary can be found on radiopaedia.org:

Bosniak renal cyst classification

Author:  Russell Jones, MD

References

1.  Weerakkody Y, Gaillard F, et al.  Bosniak renal cyst classification.  www.radiopaedia.org.  Accessed 5/2013.

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Great example of a pleural effusion

June 10, 2013

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This patient came in dyspenic, has a history of metastatic lung cancer:

Pleural effusion

This is a good example of a pleural effusion.  The upright chest xray shows a fluid level on the right representing a large right pleural effusion.  The patient had a therapeutic thoracentesis and felt much better.

Author:  Russell Jones, MD

Image Contributor:  Carieann Drenten, MD

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What to do with a thumb dislocation?

June 7, 2013

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This patient presented with thumb pain after an MVC:thumb mcp 2thumb mcp3

The xray shows a dorsal dislocation at the thumb MCP joint, some fragments concerning for avulsion fractures as well.  The mechanism was likely hyperextension from the steering wheel.  It is important to note that this type of injury is almost always associated with complete disruption of the volar plate and is often associated with collateral ligamentous injury.  This results in an unstable MCP joint even after reduction.  The thumb MCP is a very important joint and instability can lead to decreased pincher grasp function causing significant morbidity long-term.   Operative indications according to Wheeless’ Textbook of Orthopedics include:

1.  Inability to reduce

2.  Radial or ulnar instability >40 degrees after reduction (stress xray views can help quantitate)

3.  Fracture through the sesamoids

Thumb MCP dislocation

We had good success reducing this after a median nerve block.  Clinically the joint was very unstable with stress angles nearing 60 degrees.  The patient was placed in a thumb spica splint and referred to hand surgery.

Author:  Russell Jones, MD

References:

1.  Dislocations of the Thumb MP Joint. Wheeless’ Textbook of Orthopedics online.  http://www.wheelessonline.com/ortho/dislocations_of_the_thumb_mp_joint  Accessed: 5/2013

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Answer to chest Xray…

June 2, 2013

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The other day I posted this Chest Xray on an individual with cough, fevers:

PJP PNA

The xray shows diffuse interstitial infiltrates concerning for an atypical pneumonia.  The patient had several weeks of weight loss, fatigue, fevers and he had profound hypoxia into the 40s on room air.  The differential diagnosis in this situation is broad and can include common atypical bacterial pneumonia organisms (Mycoplasma, chlamydia sp, legionella, etc).  ARDS can present like this with diffuse infiltrates and hypoxia.  Influenza is also on the list of pathology.  However, the significant hypoxia also brought up Pneumocystis Jiroveci pneumonia.  An LDH was added and came back at 439 U/L (normally <200).  The patient was empirically covered with common community-acquired antibiotics plus TMP/SMX, steroids for PJP and admitted to the hospital.  His CD4 count came back 10 and a broncheoalveolar was positive on immunofluroescence testing for Pneumocystis Jiroveci.

Author:  Russell Jones, MD

Image Contributor:  James Chenoweth, MD

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