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Crazy 5th finger fracture…

June 16, 2016

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This patient presented with pain after jamming their finger:

 

Interesting fracture pattern!

On the AP view the fracture is subtle; the distal end of the proximal 5th phalanx looks irregular and lacks a solid radial side.  On the lateral it is more obvious.  The fracture line appears to have travelled obliquely and it almost looks like there are two distal phalanx!  The distal portion of the finger is dislocated at the PIP joint.

Author:  Russell Jones, MD

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WWWTP #24 Answer…

July 1, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

The patient’s chest tube is not inserted far enough.  It is also a bit high residing between ribs 3-4.

Chest tubes have a side port and a distal port for suctioning fluids, air from the pleural space.  There is a radiopaque line seen on the tube that is interrupted at the side port (see magnified image).  In this case the radiograph shows that the side port is subcutaneous and not inserted all the way into the pleural space.  The chest tube needs to be replaced!

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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What’s Wrong With This Picture #24 (WWWTP?)

June 26, 2015

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Trauma patient came in to the ED:

CXR 1

What’s Wrong With This Picture?

Author:  Russell Jones, MD

Image Contributor:  David Barnes, MD

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Student Corner: Air Everywhere

May 19, 2015

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This time, we have an interesting CXR to examine. There are three distinct places in the image below where air is in places it shouldn’t be. Can you identify them?

sp EGD 1

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Need a refresher on how to read a CXR? This post will help you out.

Scroll down further for the answer.

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PTX, SubQ, Pneumoperitoneum post EGD

Image Key: Blue arrows–supraclavicular subcutaneous emphysema; Purple arrows–pneumothorax; Red arrows = pneumoperitoneum

Pneumothorax: air in the pleural space

On an upright CXR, a pneumothorax is one of the more easily identifiable pathologies in the thoracic cavity. The presence of air separates the parietal pleura and visceral pleura, resulting in the lung tissue being pushed towards midline. This results in the edge of the lung tissue being easily identifiable (purple arrows). The rest of the cavity is devoid of lung markings.

It is important to note that the size of a pneumothorax can vary greatly. Therefore even if the absence of lung markings isn’t as striking as it is in this picture, the edges of the thoracic cavity should always be closely examined to see if there is any evidence of air. On the other extreme is a tension pneumothorax, which is defined as an expanding pocket of air in the thoracic cavity, which causes half of the lung to completely collapse and shift the mediastinal structures in the contralateral direction.

Pneumoperitoneum: air in the abdominal cavity

The presence of air in the abdominal cavity comes from two major sources: outside the body or the GI tract. Air from outside the body enters into the abdominal cavity through either iatrogenic (surgery, peritoneal dialysis) or traumatic (penetrating wound) routes. Air from the GI tract enters if any segment of the bowel is perforated (most commonly secondary to a duodenal ulcer). On an upright CXR, as is shown above, the air rises to the level of the diaphragm and can be identified.

Even though the subdiaphragmatic air in this picture is clearly evident, CXR’s are not the gold standard diagnostic test for pneumoperitoneum. Abdominal CT scans can pick up much smaller amounts of air that may be difficult to visualize on a plain film.

Subcutaneous Emphysema: air in subcutaneous tissue planes

The image above has distinct areas of radiolucency in the supraclavicular area as a result of air tracking in the subcutaneous tissue, which is defined as subcutaneous emphysema. The area is patchy from the infiltration of air into soft tissues.

Similarly to pneumomediastinum, the air comes from either inside the body (secondary to pneumothorax, pneumomediastinum) or outside the body (penetrating trauma, chest tube insertion site). The air travels along fascial planes between the dermal and muscular layers. Another, more serious, cause is necrotizing fasciitis. In this case, however, it is likely that the air entered into the subcutaneous tissues as a result of trauma, which also resulted in a pneumothorax.

Author: Jaymin Patel

Image Contributor: Katren Tyler, M.D.

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Rare arm fracture…

April 21, 2015

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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

 

References

1.  Essex Lopresti Fracture.  Wheelessonline.com.  Accessed 4/2015.

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WWWTP #23 (What’s Wrong With This Picture?) Answer

March 12, 2015

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Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  The Xray showed free air under the diaphragm.

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

Turns out this patient has pneumatosis cystoides intestinalis.  He has a history of this disorder and has had a prior laparoscopy showing multiple cystic structures in the intestinal walls.

Findings on imaging:

1.  Chest Xray:  Concern for free air underneath the diaphragm.  He also has a tracheostomy, pacemaker, scoliosis, and a right lower lung infiltrate.

2.  CT abdomen/pelvis:  The coronal imaging shows multiple cystic structures full of free air in the cecal area.  The cross-sectional imaging above shows a large amount of pneumoperitoneum.

Luckily this patient has a history of pneumatosis cystoides intestinalis.  He has had multiple abdominal CT’s showing similar findings.  Clinically he had no abdominal tenderness.  Keep this rare diagnosis in mind for the patient presenting with free air in the abdomen!  Information about pneumatosis cystoides intestinalis:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235639/

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD

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Rice bodies…

January 15, 2015

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Elderly gentleman came to the ED because he was wandering around the neighborhood.  A bystandard called 911.  He was pleasantly confused, had a mental status consistent with dementia.  The only other pertinent physical exam finding was some erythema, cellulitic appearance to his ankle.  We obtained a tibia and fibula xray looking for gas in the setting of cellulitis and this is what we found:


Rice bodies 2Rice bodies 1

 

The densities in the soft tissue of his legs are “Rice bodies.”  They are sometimes seen in systemic cysticercosis.  These bodies are calcified dead cysts from the organism Taenia Solium.  Typically this tapeworm is found in pork.  Taenia Solium is rare in the U.S., it is more prevalent in underdeveloped countries especially with a diet that has potential to include raw or undercooked pork.  This should also be on your differential with new onset seizures (1).

 

Multiple calcifications 1

 

He also had rice bodies on head CT.  Possibly the cause of his dementia?

Author:  Russell Jones, MD

References

(1) Parasites – Taeniasis.  http://www.cdc.gov/parasites/taeniasis/.  Accessed 1/2015.

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Student Corner: A Cavitary Lesion

January 6, 2015

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Cavitary lesions in the lungs are gas or fluid filled compartments in an area of pathology, such as a consolidation or a mass. Interestingly, a specific set of pathologies are known to cause this specific finding. Cavitary lesions can be detected on a chest x-ray, as is shown below.

cavitary-mass with IDCavitary masscavitary mass lateral with IDCavitary mass 2

Legend: Red Ellipse–cavity (with margins), Blue Ellipse–air-fluid level

The lesion practically jumps out of the picture on the AP view, but the colored circles are there just to point out the entire area of pathology (blue) and the cavity within (red). The pathology is a bit harder to see on lateral view, but the cavity has an air-fluid level that is easily identified as a vertical line separating a lighter fluid filled portion from an air filled portion. This air-fluid interface is often called a meniscus. You might remember being in chemistry class and measuring water out of tall beakers where the water stuck to the sides of the glass creating a concave meniscus. The surface tension of water allows it to stick to both itself and surrounding surfaces. If you look close enough, you’ll notice that the air-fluid level in the image above, best visualized in the AP view, has a slightly concave shape because the liquid at the bottom is sticking to the solid sides of the cavity.

The underlying pathophysiology is an interesting concept to understand when discussing cavitary lesions. A cavity can form in lung tissue for various reasons, but infection is the major underlying cause. Abscesses are localized collections of pathogens, fluid and immune system components that are walled off from the surrounding tissue, therefore creating a fluid-filled cavity. Tuberculosis is a disease process that involves caseous necrosis, which results in coagulation of cell proteins and liquefaction of cellular components. Eventually, the liquid portion drains out through the lymph system or through the bronchi, leaving air pockets behind. Necrotizing pneumonia and non-infectious processes such as ischemia and neoplasm can also cause a similar picture. Rheumatologic diseases such as granulomatosis with polyangitis and sarcoidosis also cause cavitary lesions by causing localized inflammation, which in turn leads to an area of increased mass, which then in turn can cavitate once the inflammatory reaction recruits fluid to the area. In other words, most of these processes, even if they aren’t inherently related to one another, all converge on the same mechanism of causing a localized area of inflammation.

With such a wide array of categories to choose from, it is perhaps more important than usual to contextualize the radiographic image with information about the patient.

This particular patient is a 30 year old male who presents with a cough.  He has been traveling around the world to multiple continents including Sub-Saharan Africa.  The extensive travel history, including to continents with rare infectious diseases leaves infection at the top of the differential. Things like Staphylococcal pneumonia, fungal infections and even amebiasis are possible because of the patient’s travel history. For a complete list of the infectious causes of a cavitary lesion, check the first two references at the bottom of the page.

References/resources:

Gadkowski LB, Stout JE. Cavitary Pulmonary Disease. Clinical Microbiology Reviews 2008;21(2):305-333. doi:10.1128/CMR.00060-07. (LINK)

Ryu, Jay H. et al. Cystic and Cavitary Lung Diseases: Focal and Diffuse. Mayo Clinic Proceedings , Volume 78 , Issue 6 , 744 – 752. (LINK)

Good pathologic image of caseous necrosis with resulting cavitation

Image Contributor:  James Luz, MD

Author:  Jaymin Patel

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What valve has been replaced?

December 16, 2014

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Here is a patient with a cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat

RadDaily.com helps with this dilemma:

http://www.raddaily.com/whitepaperarticle.php?articleTitle=Cardiac+Valves:+Assessment+and+Identification

If we apply the rules from RadDaily.com to our patient, it appears he has an aortic valve:

Valve Lat EditedValve Lat

Valve AP editValve AP

AV = Aortic Valve*

TV = Tricuspid Valve*

MV = Mitral Valve*

PV = Pulmonic Valve*

*These are anticipated locations.  The locations could be altered if the patient has anatomic variations such as chamber enlargement, cardiac rotation, etc.

RadDaily also has additional information using flow directional clues from the shape of the valves.  Check it out!

Author:  Russell Jones, MD

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What valve has been replaced?

December 10, 2014

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Here is a patient with a prosthetic cardiac valve…he did not know which valve was replaced.  Which one is it?

Valve AP Valve Lat

Answer to follow.

Author:  Russell Jones, MD

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