Archive | May, 2014

Antibiotic beads in a knee…

May 26, 2014

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This patient had a history of osteomyelitis of his distal femur and a septic knee.  This caused significant destruction requiring knee replacement and antibiotic bead placement (the radio opaque spherical objects).  He re-presented several weeks later with fever and knee pain:

Antibiotic beads 1

Antibiotic beads 2

There are multiple issues with these radiographs that are chronic.  It was helpful clinically to have a comparison which showed that the hardware was all intact and unchanged.  The ACUTE finding on this radiograph is radiolucency under the patella (as well as proximal to the patella) concerning for gas.  This patient was taken to the operating room for a septic joint (again).

Author:  Russell Jones, MD

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WWWTP #16 Answer…

May 22, 2014

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Several days ago I asked What’s Wrong With This Picture (WWWTP #16):

Elbow fx 3Elbow fx 2Elbow fx 1

Here’s what radiology thought:

1.  There is a fracture of the lateral epicondyle with displacement.

2.  There is subluxation of the capitellum anteriorly.

3.  There is a minimally displaced fracture of the olecranon process.

4.  There is a large amount of soft tissue swelling adjacent to the elbow, most pronounced laterally.

5.  Exam is somewhat limited due to lack of true lateral radiograph.

 

#1 is fairly easily identified on all 3 radiographs.  #2 is readily apparent if you apply the anterior humeral line to the radiograph, see link below for further details.  #3 can be best identified by the lucent line on the latter two radiographs.  #4 is apparent also on the second two radiographs.  #5 is a true statement, it is not a great lateral radiograph.  However, can you imagine the difficulty the radiology tech had trying to get anatomic landmarks when it is this swollen?

Hopefully you got all the findings!

Here is a brief review of the anterior humeral line of the elbow from radiopaedia.org:

Anterior Humeral Line

Author:  Russell Jones, MD

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What’s Wrong With This Picture #16 (WWWTP)?

May 19, 2014

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Here’s a child who fell on an outstretched hand.  Can you identify all of the findings on this radiograph?

Elbow fx 3 Elbow fx 2 Elbow fx 1

Answer to follow…

Author:  Russell Jones, MD

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Multifocal opacities…

May 12, 2014

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A patient presented to the ED with flu-like symptoms in the height of flu season:

multifocal opacities

Chest CT:

Multifocal opacities CT 2 Multifocal opacities CT

The CT demonstrates multifocal opacities with some cavitation on the larger lesions.  There seems to be a peripheral and lower-lobe predominence.  This could represent atypical pneumonia (legionella, mycoplasma, chlamydia), fungal pneumonia (cocciodomycosis, histoplasmosis, aspergillosis), miliary tuberculosis, metastatic lesions or carcinomatosis, septic emboli, or viral pneumonia.

After a significant inpatient workup the final diagnosis was Human Metapneumovirus.  All others were ruled out and viral testing revealed this culprit.

Image contributors:  David Barnes, MD and Julie Phan, MD

Author:  Russell Jones, MD

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Interesting osteomyelitis…

May 6, 2014

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This patient presented with multiple skin lesions with an ulcerative mass to his thumb…

OM hand

This patient had an ulcerative, indurated lesion to the distal thumb which can be seen on the above radiograph.  The radiograph also demonstrates periostitis and osseous erosion of the distal thumb and metacarpal joint of the thumb.  There are subtle periosteal changes to the third phalanx as well.

It turns out this patient has sporothrix schenkii osteomyelitis.

Author:  Russell Jones, MD

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Is the KUB dead?

May 1, 2014

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Before CT abdomen became commonplace in the ED, a plain radiograph of the abdomen (KUB for Kidneys, Ureters, and Bladder) was often a screening for kidney stone.  Currently, ultrasound and CT abdomen are used quite often to diagnose ureterolithiasis as they offer much more information.  Is the KUB dead?

The answer is no.  KUB still has a place particularly in monitoring the progress of known kidney stones.  I personally use them for repeat customers to assess progress (or more often prove to urology that they have not progressed).  Helpful hint:  if a patient is presenting for a second ED visit for kidney stone pain, check their scout film if they had a prior CT.  If you can see the stone on scout film, you can definitely re-image the patient with a KUB to reevaluate the location of the stone.  Here is an image of an 8mm stone in the upper right ureter (lateral to L3)  as seen on KUB:

KUB stone

This patient has an 8mm stone and presented to the ED with failed outpatient management.  The stone hadn’t moved from a prior CT scan after 1 week of symptoms.  Urology elected to take the patient to the OR for operative management. 

Please comment if you have another good use of the KUB in the ED. 

Author:  Russell Jones, MD

 

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