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Rare arm fracture…

April 21, 2015


Elbow GF1 Elbow GF2 Wrist GF 1 Wrist GF2

This patient presented with arm pain after a fall.  The radiographs obtained showed a distal radius fracture along with a radial head fracture (irregularity and bone fragment seen at the radial head).

I haven’t seen this fracture pattern before.  I’m not sure if it can be classified as an Essex-Lopresti fracture (radial head fracture accompanied by dislocation of the radioulnar joint).  In looking at the radiographs I believe the radioulnar joint is still intact.  However, I’m wondering if the clinical principle of the Essex-Lopresti fracture is maintained:  is there a disruption of the interosseous membrane between the radius and ulna.  This disruption can lead to serious long-term disability including pain, loss of pronation, supination and extension range-of-motion (1).

Has someone out there seen this before?  Any pearls of wisdom regarding this fracture pattern?

Author:  Russell Jones, MD

Imaging Contributor:  Joe Barton, MD



1.  Essex Lopresti Fracture.  Accessed 4/2015.

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Maisonneuve Fx…

August 14, 2014


This patient presented to the ED after twisting their ankle playing basketball.  Notably on clinical exam the patient also had pain to palpation near the proximal lower leg:


Massoneuve Fx 2

Massoneuve Fx 3

These radiographs show two clearly visible fractures on the proximal and distal fibula.  Also noted is some widening of the mortis on gravity stress view and if you look closely on the anterior tib/fib image (top) there is a comminuted proximal tibia fracture.  The injury pattern seen here is an example of a Maisonneuve type fracture.

A Maisonneuve fracture occurs when with disruption of the distal tibiofibular syndesmosis is associated with a proximal fibular fracture.  Often a medial malleolar fracture will be seen as well (not in this image).  This is an unstable fracture pattern that often needs operative intervention.  This image has an additional proximal tibia fracture that isn’t usually classic for a Maisonneuve fracture pattern.

In order not to miss this fracture one should always perform a proximal lower leg exam with all ankle injuries!  Image the entire fibula if there is pain.

Author:  Russell Jones, MD


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WWWTP #17 Answer…

June 30, 2014


This is a pediatric radiograph of a patient with wrist pain after a fall:

SHII fx distal radius II SHII fx distal radius


There is a subtle linear lucency on the distal radius, best seen on the lateral view.

This is a Salter-Harris Type II Distal Radius fracture.  For a refresher on Salter-Harris classification see:


Author:  Russell Jones


1.  Salter-Harris Fracture.–Harris_fracture

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Bad orthopedics…

March 19, 2014


A patient presents with foot pain after a fall from a ladder:

Foot fracture 1 Foot fracture 2

This foot X-ray shows a hindfoot dislocation at the talo-navicular and calcaneo-cuboid joints with varus angulation.  This pattern is suggestive of a Chopart’s fracture/dislocation.

What is a Chopart’s fracture/dislocation?  Glad you asked!  It is a dislocation at the specified joints above (talo-navicular and calcaneo-cuboid).  This hindfoot joint is commonly referred to as the Chopart joint.  Please see for further discussion and an even clearer X-ray for educational purposes:

Chopart’s Fracture/dislocation

It is important to understand that this is a HIGH energy mechanism.  With these high energy mechanisms it is also important to consider other injuries including proximal tibia, hip, and lumbar spine injuries.  This patient also had:

Tibial plateau fx 2 Tibial plateu fx 1

This is a quite comminuted fracture of the tibial plateau that may even make an orthopedic surgeon cringe.

Author:  Russell Jones, MD

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Pediatric back pain (answer)…

March 7, 2014


Several days ago I presented an early teenage patient with back pain:

ES of spine 1 ES spine 2

This patient has an osteolytic lesion at T11 which was later biopsied and found to be Ewing’s Sarcoma of the spine.  Roughly 10% of Ewing’s Sarcoma will primarily present in the spinal column.  Pediatric spinal column tumors are very rare but should be kept on the differential diagnosis of pediatric back pain.  Unlike adults, pediatric patients rarely present to the ED with the chief complaint of back pain.  Pyelonephritis and acute trauma are the leading pathology but malignancy should be explored if the clinical scenario is worrisome (weight loss, night sweats, neurologic signs, or unrelenting pain over weeks/months, central spinal tenderness). 

For more information on Ewing’s Sarcoma of the spine here is a summary article from Skeletal Radiology:

Ilaslan H, et al.  Primary Ewing’s sarcoma of the vertebral column.  Skeletal Radiol 2004 Sep; 33 (9): 506-13.

Author:  Russell Jones, MD

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LeFort would cringe…

December 14, 2013


Motorcycle accident:

CT face 2 CT face 3 CT face...

CT face 3D

This patient has severe facial trauma, comminuted fractures of most (if not all) of his facial bones, a ruptured right globe. 

A review of facial fractures including the LeForte classification, courtesy of the University of Washington:

Facial Fractures

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Distal Radius…

October 2, 2013


Distal Radius 1 Distal Radius 2

This is an example of a distal radius fracture that needs closed reduction.  This fracture shows dorsal and radial angulation with translational displacement of the fracture fragment roughly 50% of the bone width.  The classic eponym for this type of fracture is a Colles’ Fracture. 

Acceptable angulation on reduction is a controversial topic.  It is obviously best to get these fractures as close as anatomic as possible with less than 10-15 degrees of angulation.  Remember to get a post-reduction X-ray so that when it falls off prior to the follow up ortho visit then you can’t be blamed!

Author:  Russell Jones, MD

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20 year old male with wheezing…

September 6, 2013


20 year old male presents with neck fullness and wheezing.  Had the sensation of “fullness” for about a year, worsening significantly over the past week.  Now he complains primarily of trouble swallowing and wheezing.

On exam the patient has a definite right sided neck mass, minimally mobile but unclear if associated with the thyroid.  Lungs with a biphasic wheeze and sats low 90s.  Positive Pemberton’s sign with facial plethora and JVD when he raised his arms above his head.  Here is his neck CT with IV contrast:

CT scout goiter CT goiter 1 CT goiter 2

The CT revealed a 4.9 x 4.2cm multi cystic mass occupying the right lobe of the thyroid with some tracheal compression.  TSH <0.02.  The patient was admitted and approximately 45ml of fluid was drained from his cystic lesion with significant improvement in his symptoms initially, although this fluid recurred over the subsequent month.  He is currently being worked up for thyroid pathology and may undergo a hemithyroidectomy in the near future.
On a side note, here is a NEJM article discussing “Pemberton’s Sign”:
Of note, there is some controversy surrounding the use of iodinated contrast in patient’s with suspected thyroid masses.  This iodine bolus may interfere with a subsequent radioiodine scan, and theoretically may delay a patient’s therapy with radioactive iodine, if ultimately indicated.
Image Contributor:  Aaron Hougham, MD

Author:  Aaron Hougham, MD


1.  Basaria S, Salvatori R.  Pemberton’s Sign.  N Engl J Med 2004; 350: 1338.

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Bosniak classification for renal cysts…

June 14, 2013


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

Bosniak renal cyst classification

Author:  Russell Jones, MD


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

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Pancreatitis CT…

May 18, 2013


A colleague pointed out an interesting CT on a patient with epigastric pain…

Pancreatitis CT2Pancreatitis CT1Pancreatitis CT 3

This CT shows stranding around the pancreas with fluid tracking in Gerota’s fascial plane.  What is Gerota’s fascia you say?

Gerota’s fascia (otherwise known as “Renal Fascia”) is the layer of connective tissue surrounding the kidneys and suprarenal glands.  Anterior to this fascial compartment is the prerenal space which contains the pancreas, ascending colon, descending colon, and the second-fourth portions of the duodenum.  Any inflammation with these organs can lead to fluid within Gerota’s fascia.  On the CT above this is demonstrated by the fluid stripe anterior to the left kidney on the middle image (sagittal plane)  and superior to the left kidney on the third image (coronal plane).  For an anatomic picture of Gerota’s fascia see the following Wikipedia reference:

Gerota’s Fascia

Author:  Russell Jones, MD

Image Contributor:  Tag Hopkins, MD


1.  Renal Fascia.  Accessed: 5/2013

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