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WWWTP #17 Answer…

June 30, 2014

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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:

Salter-Harris

Author:  Russell Jones

References

1.  Salter-Harris Fracture.  http://en.wikipedia.org/wiki/Salter–Harris_fracture

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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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Reasons not to try relocation of hips…

April 7, 2014

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Dislocated hip

On this pelvis Xray you can see two hip replacements, the left one is dislocated.  If you look closely you can also see a fracture line just superior to the prosthesis near the greater trochanter.  Be careful reducing these without obtaining orthopedics input. 

The other prosthesis is interesting.  It is a hip replacement with a constrained acetabular liner.  You can see a radioopaque ring around the femoral head component of the arthroplasty.  This is a ring that functions to hold the hip in place.  If this dislocates (not in this case), then this requires open surgical intervention for relocation.  Don’t try to put one of these back in!

Image Contributor:  Hollis “Tag” Hopkins, MD

Author:  Russell Jones, MD

References

1.  THR: Constrained Acetabular Liners.  http://www.wheelessonline.com/ortho/12698

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Bad orthopedics…

March 19, 2014

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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 radiopaedia.org 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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Stabbed in the chest…

January 29, 2014

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This patient was stabbed in the chest multiple times.  Markers showing the external stab wounds to the lateral chest wall on the right side:

HemoPTX stabbed

This is a classic trauma chest xray with a hemopneumothorax on the right side.  This patient has a great indication for a large-bore chest tube!  Not only to reexpand his lung but to monitor hemothorax output and need for emergent thoracotomy to evaluate the source of bleeding.  Trauma recommendations from the Journal of Trauma in 2010 concerning hemothorax include:

1.  Patient physiology should be the primary indication for surgical intervention rather than absolute numbers of initial or persistent {chest tube} output (Level I recommendation)

2.  1500 ml via a chest tube in any 24-hour period regardless of mechanism should prompt consideration for surgical exploration (Level II recommendation)

3.  All hemothoracies, regardless of size, should be considered for drainage (Level III recommendation)

Please see the EAST Trauma Guidelines for further details:

Mowery NT, et. al.  Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax.  J Trauma 2011; 70 (2): 2011. 

Author:  Russell Jones, MD

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Interesting finding on “Pan Scan”…

January 24, 2014

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The trauma “Pan Scan” has been a controversial topic for a while now.  “Pan Scan” has multiple meanings but is usually some combination of head, c-spine, chest and abdomen CT imaging to identify serious traumatic related injuries.  Downsides include cost, radiation, and contrast.  Upsides include early identification of serious trauma including solid organ injuries.  Here is an interesting case that presents an original argument for the “Pan Scan:”

Pills in skin folds 2 Pills in skin folds

This person came in with altered mental status and trauma (single car MVC).  CT identified a large number of hidden pills later identified as an opioid pain medication.  They were hidden in an abdominal fold just above the pubis!

(Disclaimer:  Please don’t misinterpret this as an argument to identify pills with a pan scan.  It would have been much more cost effective to find them on physical exam)

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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I think I got stabbed in the eye…

January 18, 2014

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Patient presented after an altercation.  He thinks he got stabbed in the eye with a “razor blade or a pencil.”  Eye was swollen shut and unable to be opened due to significant edema:

Pencil orbit 1 Pencil Orbit 2

This patient has a radioopaque foreign body just lateral to the globe.  It is penetrating into the posterior orbital fossa but doesn’t appear to be causing proptosis or retrobulbar hematoma.  It does indeed look like a pencil!

Author:  Russell Jones, MD

Image Contributor:  Ken Kelley, MD

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LeFort would cringe…

December 14, 2013

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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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Answer: Can you find the abnormalities?

December 2, 2013

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I gave you this xray a couple days ago, can you find all the abnormalities?

GSW

1.  Intubated into the right mainstem bronchus

2.  Metallic foreign bodies coursing up the left chest to the neck

3.  Completely opacified left lung:  differential diagnosis of pulmonary contusion, hemothorax, or complete atelectasis from right mainstem intubation

4.  There is a chest tube in the right chest cavity, it looks to be in good position but could be coursing into the fissure between the left lobes

5.  Deep sulcus sign on the left side indicates possible pneumothorax vs. hemothorax

6.  Orogastric tube courses below the diaphragm in good position

7.  Subcutaneous emphysema in upper neck

8.  Two radiodense objects in the midline cardiac silhouette near the mid-portion of the coursing orogastric tube

Interestingly, this patient was shot in the chest coursing to the upper neck and the bullet was found in his posterior pharnyx.  He had a tooth found on chest CT (calcified opacity seen below) among other injuries.   Later EGD intraoperatively showed two tooth fragments in the stomach.  The radiodensities seen #8 above were presumed to be these teeth in the esophagus.

Tooth

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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Can you find all the abnormalities?

November 28, 2013

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This patient came in after a reported gunshot wound.  Can you find all the abnormalities in this xray?

GSW

 

Answer to follow.

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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