Watch out!  The ET tube is malpositioned into the right mainstem bronchus.  This emergency required us to call the ER doctors because removal and repositioning of the ET tube is warranted.

Observation

Clinical History: s/p cardiac arrest.

Technique: DX chest, portable 1 view

ET tube with its tip in the right mainstem bronchus. Suggest retraction by about 5 cm. There is marked cardiomegaly. Opacities are noted bilaterally more on the suprahilar and perihilar regions with air-bronchograms. Followup with PA and lateral chest radiograph is recommended.

Impression

APPARENT MALPOSITION OF ET TUBE, AS DESCRIBED. SUGGEST RETRACTION BY ABOUT 5 CM. MARKED CARDIOMEGALY. FINDINGS IN THE LUNGS POSSIBLY DUE TO PULMONARY EDEMA OR PNEUMONIA. RECOMMEND FOLLOW-UP.

Textbook case of Emphysematous pyelonephritis, which is incredibly rare these days given the super strong antibiotics available…

Observation

Clinical history: Rule out PE, chills, elevated D-dimer

Technique: CT scan of the chest and bilateral lower extremity venogram with intravenous contrast

No CT features of pulmonary embolism in the central pulmonary arteries. However, evaluation of the peripheral subsegmental vessels is limited by a suboptimal bolus of contrast and small peripheral emboli cannot be entirely excluded. The pulmonary arteries are prominent, suggesting an element of possible pulmonary arterial hypertension. Calcified granulomas are noted in the lungs bilaterally. No pleural effusion or pneumothorax is seen. No pericardial effusion is seen. Mild cardiomegaly is noted. Calcified right hilar lymph nodes are noted. The aorta is unremarkable without aneurysm or dissection. Degenerative changes of the spine are noted. The left kidney is severely enlarged with severe hydronephrosis and significant cortical thinning. There are air fluid levels within the left kidney, suggestive of emphysematous pyelonephritis. There is an approximately 9 cm diameter abscess off the upper pole of the left kidney centered on approximately image 163 which at its lower aspect on image number 165 appears to necessitate through the renal capsule and extend through left lateral abdominal wall possibly involving the lateral extra peritoneal abdominal wall musculature. There is a second large abscess which appears to extend from a left medial inferior renal calyx to involve the psoas muscle. This also has associated gas within it consistent with a large abscess necessitating from the kidney to the psoas muscle. A few small bowel loops are prominent, likely representing ileus. Bilateral lower extremity veins are well opacified. No filling defect is noted to suggest deep vein thrombosis.

Impression

Chest CT impression: No Ct features of pulmonary embolism in the central pulmonary arteries. However, evaluation of the peripheral subsegmental vessels is limited by suboptimal bolus of contrast as well as breathing motion artifact and small peripheral emboli cannot be excluded. Correlate clinically. Consider further evaluation with nuclear medicine ventilation perfusion scan.

Abdominal CT report: severe emphysematous pyelonephritis with two large abscess is one which necessitates to the lateral abdominal wall likely extending into the extra peritoneal deep muscle layer. A second appears to necessitate from the lower medial renal calyx to involve the psoas muscle. Follow up recommended. No CT features of deep vein thrombosis.

This case shows laterally dislocated 2nd through 5th metatarsal bones relative to the tarsals and suggests a Lisfranc dislocation, named after Jacques Lisfranc, who, as a field surgeon in Napoleon’s army, described an innovative technique to amputate the forefoot of soldiers as a means to treat frostbite. Of the two basic types, our patient appears to have the Homolateral type, wherein all the metatarsals are dislocated to one side.

Further reading:
http://emedicine.medscape.com/article/1236228-overview

Observation

Clinical History: Pain, swelling, ankle and foot fractures

Technique: DX left foot (3 views)

Compared with prior study dated February 2, 2010 (21:03)

The presence of cast material obscures subtle bony detail, limiting the study. At least three well corticated osseous structures posterior to the talus are again seen, unchanged. Partly imaged fractures of the medial and lateral malleolus show no significant interval change and are described in detail in the accompanying ankle films. The mineralization of the visualized bony structures is well maintained. Soft tissue swelling around the ankle joint is again seen and appears unchanged. Compared to the pre-reduction film, a lateral displacement of the second through fifth metatarsals and possibly also of the first metatarsal in relation to the tarsal bones, is now more apparent.

Impression

INTERVAL PLACEMENT OF CAST. LATERAL DISPLACEMENT OF THE SECOND THROUGH FIFTH METATARSALS IN RELATION TO THE TARSAL BONES, AND PROBABLY OF THE FIRST METATARSAL IS NOW MORE APPARENT, SUGGESTIVE OF A LISFRANC DISLOCATION. FURTHER EVALUATION WITH MRI MAY BE OF BENEFIT. OTHERWISE STABLE STUDY OF THE LEFT FOOT.

Today’s case is a rare condition where there is transposition of a loop of large intestine (usually transverse colon/hepatic flexure of the colon) in between the right diaphragm and the liver, as seen in on plain abdominal X-ray or chest X-ray. It is said that this seen in only about 0.1-1.0% of chest x-rays.

Observation

Clinical History: Pre-op

Technique: DX chest 2 views

The cardiomediastinal silhouette appears to be within normal limits. The lungs are hyperexpanded with flatteing of the hemidiaphragms. No acute focal infiltrate or consolidation is seen. There is presence of an air-filled bowel loop, between the liver and right hemidiaphragm, which is usually of no clinical significance.

Impression

CLEAR CHEST. CONSIDER COPD. OTHER FINDINGS AS NOTED ABOVE.

As with our patient, when large portions of the cranium have been removed by operation, external injury, or exfoliation, the brain is deprived of its support, and, by the pulsation of its arteries, the dura matter is rubbed against the rough edges of the bone, by which it ulcerates, and the brain then protrudes. This protrusion from the cerebrum is more particularly apt to occur when the dura matter has been wounded by accident or design and it may present  itself under three different forms: It may consist either of disorganized pure cerebral matter, partly of cerebral matter and of coagulated blood; or be an organized mass.

The first generally occurs immediately after the injury, and arises from the substance of the brain being wounded, and a portion of it being separated from the common mass.

The second most commonly takes place some days after the injury, and seems to arise from the rupture of one or more blood vessels a little below the surface of the brain, in consequence of which, a portion of this viscus is mechanically raised through the opening in the dura matter, skull, and integuments. This protrusion is of a dark color and is at first covered by the pia matter, but the internal hemorrhage continuing, the brain is still farther raised. This membrane then gives way. At length, the the brain yields and the blood is effused upon the surface of the tumor.

The third species of protrusion from the brain follows abscess or ulceration of that organ, hence does not appear for many days, and is as completely organized as the fungi springing from other ulcers. The fungus which arises from the brain shoots up with great rapidity, is of a greyish colour, and is generally about the size of a pigeon’s head, but, on some occasions, it is as large as a hen’s egg or a small orange. Its appearance is always preceded by an opening in the dura matter and is always connected with ulceration of the brain.

External herniations, also known as fungus cerbrei, are the rarest of the acquired herniations. They are most frequently caused by post surgical and post traumatic defects that allow swollen or displaced brain to pass through. This type of herniation may be beneficial by relieving intracranial pressure and thereby preventing more devastating complications due to internal herniation; however; external exposure of the brain can result in infections, complications, and many of these patients have a poor prognosis because of  the severity of their underlying illness. Both CT and MR imaging are effective at demonstrating these herniations. MR imaging, however, is clearly superior at defining soft tissue, which can be critical in certain clinical scenarios. Distingushing brain tissue from other tissues such as granulation tissue, cholesteatoma, tumor, or other lesions involving defects of the skull is essential and MR imaging accomplishes this well.

Observation

Clinical History: bleed, follow up

Technique: CT scan of the head without intravenous contrast

Compared with prior study dated January 30, 2010

The presence of streak artifact limits the study. There is interval development of some degree of herniation of the left frontal lobe through the left craniectomy defect with interval development of subdural hygroma in the right frontoparietal convexity and evolution of the previously noted mild left to right subfalcine herniation into a mild degree of right to left subfalcine herniation. There is partial interval improvement of the pneumocephalus in the left frontal and left parietal convexities. There is no significant interval change in the left frontotemporoparietal, parafalcine, and left paratentorial hyperdensities, which may reflect subdural hemorrhage. There is interval development of opacities in some of the ethmoid air cells and sphenoid sinuses.

Impression

INTERVAL DEVELOPMENT OF SOME DEGREE OF HERNIATION OF THE LEFT FRONTAL LOBE THROUGH THE LEFT CRANIECTOMY DEFECT. CONSISTENT WITH DEVELOPMENT OF POST-SURGICAL PSEUDOENCEPHALOCELE (FUNGUS CEREBRI). ASSOCIATED INTERVAL DEVELOPMENT OF RIGHT-SIDED SUBDURAL HYGROMA AND MILD RIGHT TO LEFT SHIFT. NO SIGNIFICANT INTERVAL CHANGE IN THE LEFT FRONTOTEMPOROPARIETAL, PARAFALCINE, AND LEFT PARATENTORIAL HYPERDENSITIES, MAY REFLECT SUBDURAL HEMORRHAGE. INTERVAL DEVELOPMENT OF OPACITIES IN THE ETHMOID AND SPHENOID SINUSES, SUGGESTIVE OF SINUSITIS. PARTIAL INTERVAL IMPROVEMENT OF THE PNEUMOCEPHALUS IN THE LEFT FRONTAL AND LEFT PARIETAL CONVEXITIES.

59 year old male trauma patient has a right shoulder xray taken to rule out fracture. The images show the head of the humerus (upper arm bone) to be in front of and below its expected location. The shoulder joint has been dislocated. No fracture is seen. There may be related injuries to the muscles and ligaments of the shoulder, however these cannot be seen on xrays, a followup MRI would be the examination of choice for such an evaluation.

Observation

Clinical History: R/o fracture

Technique: DX right shoulder

No prior study is available for comparison

The mineralization of the visualized bony structures is well maintained. There is anterior and inferior dislocation of the humerus in relation to the glenoid fossa, with the humeral head in subcoracoid location. No acute displaced fracture is identified. Degenerative changes are seen in the acromioclavicular joint.

Impression

Anterior and inferior dislocation of the humerus. No acute displaced fracture is identified.

Let’s face it:  mixing chemicals is dangerous.  Even if you know what you’re doing, there’s always the risk of something going wrong.  So was the case of today’s John Doe:

Clinical History: Chemical explosion (patient mixing chemicals when it exploded)

Technique: DX right hand, 3 views

There is complete comminuted fracture of the base of the first metacarpal with angulated dorsal displacement and intraarticular extension. There is also minimally displaced corner fracture at the ulnar side of the base of the first proximal phalanx also with intraarticular extension. Possible tuft fracture. There are multiple comminuted/shattered phalangeal fractures from the third to the fifth digit with adjacent skin and soft tissue avulsion with some areas of traumatic amputation. Also seen is undisplaced to a slightly displaced fracture of the base of the fourth and fifth proximal phalanx.