Archive | July, 2013

Humerus fracture…

July 28, 2013

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Humerus fracture

This is a mid-shaft humerus fracture.  Very common to encounter this in the ED.  What is the most common nerve injured with this type of fracture?

Author:  Russell Jones, MD

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WWWTP #8 Answer

July 22, 2013

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As you recall, this was a 25 year old female presenting with epigastric pain:

Pancreatic pseudocyst 2Pancreatic Pseudocyst 1

This CT shows a large cystic structure measuring 13cm in the epigastric area.  There are also several smaller cystic structures lying adjacent to this within the expected location of the pancreas.  There are inflammatory changes, mainly stranding surrounding these structures.

These are pancreatic pseudocysts.  In acute and chronic pancreatitis these “pseudocysts” can form causing mass effect and abdominal pain.  They can get quite large.  They are called pseudocysts because the walls are made of granulomatous tissue rather than epithelial tissue as in true cysts.  The fluid inside is rich in pancreatic enzymes, blood, and necrotic tissue.  They form when pancreatic cells lyse in acute pancreatitis; the release of pancreatic enzymes cause digestion of surrounding cellular structures and the pseudocyst forms.  Complications of pseudocysts include obstruction (intestinal, gastric, urinary, vascular), hemorrhage, infection, and rupture.  Usually these require surgical formation of a drainage tract between the cyst and an adjacent portion of the GI tract (stomach, duodenum, jejunum).

Ultrasound is another radiologic imaging modality that may used to diagnose and monitor pancreatic pseudocysts.  Unfortunately it is often limited by gastric contents and gas which can get in the way of smaller pseudocyst visualization.  CT is the gold standard.

Author:  Russell Jones, MD

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WWWTP #8 (What’s Wrong With This Picture)

July 18, 2013

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25 year old female with epigastric abdominal pain.  WWWTP?

Its easy to see the abnormality in this abdominal CT.  What is it?

Answer to follow.

Author: Russell Jones, MD

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Answer to headache/seizure…

July 16, 2013

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A couple days ago I presented a middle-aged man with headache and seizure.  What type of imaging is this and what is your differential:

Cystic brain lesion CTT2 MRI cystic lesion

The top image is a non-contrast CT of the head.  The second image is an axial T2-weighted MRI of the head

Both images demonstrate a multi-cystic lesion in the left parietal area.  The MRI demonstrates significant surrounding edema.  A course differential for an intraparenchymal cystic brain lesion includes:

  • Parasitic infection (neurocysticercosis, hyatid cyst from Echinococcus granulosus)
  • Abscess
  • Tuberculosis
  • Neoplasm (craniopharyngioma, glioblastoma, metastases, and more…)
  • Enlarged periventricular spaces (Virchow-Robin spaces)
  • Benign cyst (e.g. neuroglial cyst)

I found a good article in Radiology that covers all types of brain cysts:

Osborn AG, Preece MT.  Intracranial Cysts:  Radiologic-Pathologic Correlation and Imaging Approach.  Radiology 239 (3); 2006.

Unfortunately I don’t have an answer to what this patient had, they are currently awaiting brain biopsy for further evaluation. 

Author:  Russell Jones, MD

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Middle-aged man with headache and seizure…

July 12, 2013

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Middle-aged man presents with headache and seizure:

Cystic brain lesion CT

T2 MRI cystic lesion

What type of imaging modalities are demonstrated above and what is your differential?

Answer to follow

Author:  Russell Jones, MD

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“Doc I’m a little short of breath…”

July 9, 2013

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I had a man present the other day with dyspnea, mostly on exertion, minimal pleuritic chest pain.  He was hemodynamically stable while sitting in the gurney but would desaturate to the high 80s and become tachycardic with walking several feet.  He had a history of recently diagnosed multiple myeloma and was awaiting treatment initiation.  Here’s what we found on Chest CT:

Central PE 2Central PE 1

 

The chest CT shows a “saddle embolus.”  This is a pulmonary embolus that is very large and located in the proximal pulmonary artery before it bifurcates into the right and left pulmonary arterial tree.  This type of pulmonary embolus represents a large clot burden that can easily lead to hemodynamic instability and sudden death.  In fact, it was very suprising that this patient was so stable sitting in the gurney.  Initially he was reading a book on his tablet which I usually associate with no emergent pathology! 

This is a good time to review the indications for thrombolysis in pulmonary embolus:

  • Severe hypoxemia
  • Intractable hypotension
  • Large perfusion defect on ventilation-perfusion scans
  • Extensive embolic burden on computed tomography
  • Right ventricular dysfunction
  • Free-floating right atrial or ventricular thrombus
  • Patent foramen ovale
  • Cardiopulmonary resuscitation

These are all relative indications and it is important to weigh the risks of thrombolytics on a case-by-case basis.  There are no true indications for thrombolytics.  There are many widely accepted contraindications…I’ll leave it up to the reader to search for these. 

Author:  Russell Jones, MD

References:

1.  Tapson, VF.  Fibrinolytic (thrombolytic) therapy in acute pulmonary embolus and deep venous thrombosis.  www.uptodate.com.  Accessed 7/2013.

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Knife + toe =

July 6, 2013

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What happens when you throw a knife at your toe?

DP fx toe

 

Not too astonishing that you could fracture your distal phalanx!  On exam, the patient had basically longitudinally cut his toe in half. 

Author:  Russell Jones, MD

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10 month old female throwing up…

July 3, 2013

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This child was referred to the ED after an astute primary care doctor got a chest xray in the setting of a week of throwing up after eating:

FB 2Coin 1

The PA/LAT chest xray views above show a radioopaque object near the thoracic inlet.  The object resembles the shape and size of a penny.  Interestingly, on the lateral it almost looks like two pennies lying on top of each other.  The patient was taken to the OR and esophagoscopy was used to pull two pennies out of her upper esophagus. 

On xray, how can you differentiate between tracheal and esophageal foreign bodies?

Author:  Russell Jones, MD

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