Keith D. Hentel, MD, MS

Case

A 96-year-old woman with a medical history of sciatica, vertigo, osteoporosis, and dementia presented with atraumatic right leg pain. She stated that the pain, which began 4 weeks prior to presentation, started in her right groin. The patient’s primary care physician diagnosed her with tendonitis, and prescribed acetaminophen/codeine and naproxen sodium for the pain. However, the patient’s pain progressively worsened to the point where she was no longer able to ambulate or bear weight on her right hip, prompting this visit to the ED.

On physical examination, the patient’s right hip was tender to palpation without any signs of physical deformity of the lower extremity. Upon hip flexion, she grimaced and communicated her pain.

Radiographs and computed tomography images taken of the right hip, femur, and pelvis demonstrated low-bone mineral density without fracture.

What is the diagnosis?

Answer

Axial and coronal edema-sensitive images of the pelvis demonstrated edema (increased signal) within the right psoas, iliacus, and iliopsoas muscles (red arrows, Figures 2a-2c), which were in contrast to the normal pelvic muscles on the left side (white arrows, Figures 2a-2c).

Iliopsoas Musculotendinous Unit

The iliopsoas musculotendinous unit consists of the psoas major, the psoas minor, and the iliacus, with the psoas minor absent in 40% to 50% of cases.^1,2 The iliacus muscle arises from the iliac wing and inserts with the psoas tendon onto the lesser trochanter of the femur. These muscles function as primary flexors of the thigh and trunk, as well as lateral flexors of the lower vertebral column.²

Signs and Symptoms

In non-sports-related injuries, iliopsoas tendon tears typically occur in elderly female patients—even in the absence of any trauma or known predisposing factors. Patients with iliopsoas tears typically present with hip or groin pain, and weakness with hip flexion, which clinically may mimic hip or sacral fracture. An anterior thigh mass or ecchymosis may also be present. Complete tear of the iliopsoas tendon usually occurs at or near the distal insertion at the lesser trochanter, and is often associated with proximal retraction of the tendon to the level of the femoral head.¹

Imaging Studies

Iliopsoas tendon injury is best evaluated with MRI, particularly with fluid-sensitive sequences. Patients with iliopsoas tendon tears have abnormal signal in the muscle belly, likely related to edema and hemorrhage, and hematoma or fluid around the torn tendon and at the site of retraction. In pediatric patients, iliopsoas injury is typically an avulsion of the lesser trochanter prior to fusion of the apophysis.^3,4 In adult patients with avulsion of the lesser trochanter, this injury is regarded as a sign of metastatic disease until proven otherwise.⁵

Treatment

Patients with iliopsoas tendon rupture are treated conservatively with rest, ice, and physical therapy (PT). Preservation of the distal muscular insertion of the lateral portion of the iliacus muscle is thought to play a role in positive clinical outcomes.³

The patient in this case was admitted to the hospital and treated for pain with standing acetaminophen, tramadol as needed, and a lidocaine patch. After attending multiple inpatient PT sessions, she was discharged to a subacute rehabilitation facility.

Case

A 96-year-old woman with a medical history of sciatica, vertigo, osteoporosis, and dementia presented with atraumatic right leg pain. She stated that the pain, which began 4 weeks prior to presentation, started in her right groin. The patient’s primary care physician diagnosed her with tendonitis, and prescribed acetaminophen/codeine and naproxen sodium for the pain. However, the patient’s pain progressively worsened to the point where she was no longer able to ambulate or bear weight on her right hip, prompting this visit to the ED.

On physical examination, the patient’s right hip was tender to palpation without any signs of physical deformity of the lower extremity. Upon hip flexion, she grimaced and communicated her pain.

Radiographs and computed tomography images taken of the right hip, femur, and pelvis demonstrated low-bone mineral density without fracture.

What is the diagnosis?

Answer

Axial and coronal edema-sensitive images of the pelvis demonstrated edema (increased signal) within the right psoas, iliacus, and iliopsoas muscles (red arrows, Figures 2a-2c), which were in contrast to the normal pelvic muscles on the left side (white arrows, Figures 2a-2c).

Iliopsoas Musculotendinous Unit

The iliopsoas musculotendinous unit consists of the psoas major, the psoas minor, and the iliacus, with the psoas minor absent in 40% to 50% of cases.^1,2 The iliacus muscle arises from the iliac wing and inserts with the psoas tendon onto the lesser trochanter of the femur. These muscles function as primary flexors of the thigh and trunk, as well as lateral flexors of the lower vertebral column.²

Signs and Symptoms

In non-sports-related injuries, iliopsoas tendon tears typically occur in elderly female patients—even in the absence of any trauma or known predisposing factors. Patients with iliopsoas tears typically present with hip or groin pain, and weakness with hip flexion, which clinically may mimic hip or sacral fracture. An anterior thigh mass or ecchymosis may also be present. Complete tear of the iliopsoas tendon usually occurs at or near the distal insertion at the lesser trochanter, and is often associated with proximal retraction of the tendon to the level of the femoral head.¹

Imaging Studies

Iliopsoas tendon injury is best evaluated with MRI, particularly with fluid-sensitive sequences. Patients with iliopsoas tendon tears have abnormal signal in the muscle belly, likely related to edema and hemorrhage, and hematoma or fluid around the torn tendon and at the site of retraction. In pediatric patients, iliopsoas injury is typically an avulsion of the lesser trochanter prior to fusion of the apophysis.^3,4 In adult patients with avulsion of the lesser trochanter, this injury is regarded as a sign of metastatic disease until proven otherwise.⁵

Treatment

Patients with iliopsoas tendon rupture are treated conservatively with rest, ice, and physical therapy (PT). Preservation of the distal muscular insertion of the lateral portion of the iliacus muscle is thought to play a role in positive clinical outcomes.³

The patient in this case was admitted to the hospital and treated for pain with standing acetaminophen, tramadol as needed, and a lidocaine patch. After attending multiple inpatient PT sessions, she was discharged to a subacute rehabilitation facility.

Case

A 96-year-old woman with a medical history of sciatica, vertigo, osteoporosis, and dementia presented with atraumatic right leg pain. She stated that the pain, which began 4 weeks prior to presentation, started in her right groin. The patient’s primary care physician diagnosed her with tendonitis, and prescribed acetaminophen/codeine and naproxen sodium for the pain. However, the patient’s pain progressively worsened to the point where she was no longer able to ambulate or bear weight on her right hip, prompting this visit to the ED.

On physical examination, the patient’s right hip was tender to palpation without any signs of physical deformity of the lower extremity. Upon hip flexion, she grimaced and communicated her pain.

Radiographs and computed tomography images taken of the right hip, femur, and pelvis demonstrated low-bone mineral density without fracture.

What is the diagnosis?

Answer

Axial and coronal edema-sensitive images of the pelvis demonstrated edema (increased signal) within the right psoas, iliacus, and iliopsoas muscles (red arrows, Figures 2a-2c), which were in contrast to the normal pelvic muscles on the left side (white arrows, Figures 2a-2c).

Iliopsoas Musculotendinous Unit

The iliopsoas musculotendinous unit consists of the psoas major, the psoas minor, and the iliacus, with the psoas minor absent in 40% to 50% of cases.^1,2 The iliacus muscle arises from the iliac wing and inserts with the psoas tendon onto the lesser trochanter of the femur. These muscles function as primary flexors of the thigh and trunk, as well as lateral flexors of the lower vertebral column.²

Signs and Symptoms

In non-sports-related injuries, iliopsoas tendon tears typically occur in elderly female patients—even in the absence of any trauma or known predisposing factors. Patients with iliopsoas tears typically present with hip or groin pain, and weakness with hip flexion, which clinically may mimic hip or sacral fracture. An anterior thigh mass or ecchymosis may also be present. Complete tear of the iliopsoas tendon usually occurs at or near the distal insertion at the lesser trochanter, and is often associated with proximal retraction of the tendon to the level of the femoral head.¹

Imaging Studies

Iliopsoas tendon injury is best evaluated with MRI, particularly with fluid-sensitive sequences. Patients with iliopsoas tendon tears have abnormal signal in the muscle belly, likely related to edema and hemorrhage, and hematoma or fluid around the torn tendon and at the site of retraction. In pediatric patients, iliopsoas injury is typically an avulsion of the lesser trochanter prior to fusion of the apophysis.^3,4 In adult patients with avulsion of the lesser trochanter, this injury is regarded as a sign of metastatic disease until proven otherwise.⁵

Treatment

Patients with iliopsoas tendon rupture are treated conservatively with rest, ice, and physical therapy (PT). Preservation of the distal muscular insertion of the lateral portion of the iliacus muscle is thought to play a role in positive clinical outcomes.³

The patient in this case was admitted to the hospital and treated for pain with standing acetaminophen, tramadol as needed, and a lidocaine patch. After attending multiple inpatient PT sessions, she was discharged to a subacute rehabilitation facility.

Case

A 3-year-old boy was brought to the ED by his parents for evaluation of left periorbital swelling. A few days prior to presentation, the child was seen at an outpatient center where he was diagnosed with preseptal cellulitis and given an oral antibiotic. However, even after receiving three doses of the antibiotic, the periorbital swelling and redness around the child’s eye worsened, prompting this visit to the ED.

Physical examination revealed edema and erythema both above and below the left eye, with associated tenderness to palpation. A contrast-enhanced maxillofacial computed tomography (CT) scan, with special attention to the orbits, was ordered; representative images are shown (Figure 1a-1c).

What is the diagnosis?

Answer

The CT images of the orbits demonstrated edema in the superficial left eyelid (white arrows, Figure 2a and 2b) and left deep orbital septum (red arrows, Figure 2a-2c). A peripherally enhancing fluid collection centered in the left nasolacrimal gland was present (red asterisks, Figure 2b and 2c) with mild mass effect on the left globe. Opacification was also noted within the paranasal sinuses (white asterisks, Figure 2a-2c). Together these findings indicated sinusitis with dacryocystitis and orbital cellulitis.

Dacryocystitis

Dacryocystitis is an infection or inflammation of the lacrimal sac, usually developing secondary to blockage of the nasolacrimal duct. Orbital cellulitis is an infection involving the contents of the orbit, including the fat and ocular muscles. Orbital cellulitis should not be confused with preseptal cellulitis, which is an infection involving the eyelid occurring posterior to the orbital septum. While both of these conditions are more common in children than in adults, preseptal cellulitis is much more common than orbital cellulitis.

Preseptal Cellulitis

Preseptal cellulitis is typically due to local trauma, local skin infection, or dacryocystitis.¹ Preseptal cellulitis rarely extends into the orbit, though a minority of cases have been reported in patients with concomitant dacryocystitis.² Orbital cellulitis most commonly results from paranasal sinus disease, particularly of the ethmoid sinus, which is only separated from the orbit by the thin lamina papyracea.³ While both preseptal cellulitis and orbital cellulitis can cause eyelid swelling and erythema, preseptal cellulitis is typically a mild condition. Orbital cellulitis, however, is a serious medical emergency that requires prompt diagnosis and treatment to avoid loss of vision and intracranial complications, such as venous thrombosis and empyema.³

Imaging Studies

Although the clinical features of orbital cellulitis (eg, proptosis, ophthalmoplegia, pain with ocular movement) can sometimes distinguish it from preseptal cellulitis, imaging studies are helpful to confirm the diagnosis.⁴ As previously noted, prompt recognition, diagnosis, and treatment of orbital cellulitis are essential to avoid serious complications.

Computed tomography has a high specificity and sensitivity in detecting the extension of infection into the orbit and associated complications such as subperiosteal or intracranial abscess. For patients in whom intravenous (IV) contrast is contraindicated or who wish to avoid ionizing radiation, magnetic resonance imaging is a useful alternate modality, and diffusion-weighted imaging is particularly sensitive in diagnosing abscess.⁵

Treatment

Since polymicrobial infection is common in periorbital cellulitis, broad-spectrum IV antibiotics (eg, ampicillin-sulbactam, cefuroxime, ceftriaxone, piperacillin/tazobactam) are usually indicated initially.⁶ The patient in this case was given IV ceftriaxone and clindamycin and oral amoxicillin/clavulanic acid for 3 days, after which he was discharged home in the care of his parents with instructions to complete a 14-day total course of oral amoxicillin/clavulanic acid as well as a 21-day course of fluticasone for nasal irrigation.

Case

A 3-year-old boy was brought to the ED by his parents for evaluation of left periorbital swelling. A few days prior to presentation, the child was seen at an outpatient center where he was diagnosed with preseptal cellulitis and given an oral antibiotic. However, even after receiving three doses of the antibiotic, the periorbital swelling and redness around the child’s eye worsened, prompting this visit to the ED.

Physical examination revealed edema and erythema both above and below the left eye, with associated tenderness to palpation. A contrast-enhanced maxillofacial computed tomography (CT) scan, with special attention to the orbits, was ordered; representative images are shown (Figure 1a-1c).

What is the diagnosis?

Answer

The CT images of the orbits demonstrated edema in the superficial left eyelid (white arrows, Figure 2a and 2b) and left deep orbital septum (red arrows, Figure 2a-2c). A peripherally enhancing fluid collection centered in the left nasolacrimal gland was present (red asterisks, Figure 2b and 2c) with mild mass effect on the left globe. Opacification was also noted within the paranasal sinuses (white asterisks, Figure 2a-2c). Together these findings indicated sinusitis with dacryocystitis and orbital cellulitis.

Dacryocystitis

Dacryocystitis is an infection or inflammation of the lacrimal sac, usually developing secondary to blockage of the nasolacrimal duct. Orbital cellulitis is an infection involving the contents of the orbit, including the fat and ocular muscles. Orbital cellulitis should not be confused with preseptal cellulitis, which is an infection involving the eyelid occurring posterior to the orbital septum. While both of these conditions are more common in children than in adults, preseptal cellulitis is much more common than orbital cellulitis.

Preseptal Cellulitis

Preseptal cellulitis is typically due to local trauma, local skin infection, or dacryocystitis.¹ Preseptal cellulitis rarely extends into the orbit, though a minority of cases have been reported in patients with concomitant dacryocystitis.² Orbital cellulitis most commonly results from paranasal sinus disease, particularly of the ethmoid sinus, which is only separated from the orbit by the thin lamina papyracea.³ While both preseptal cellulitis and orbital cellulitis can cause eyelid swelling and erythema, preseptal cellulitis is typically a mild condition. Orbital cellulitis, however, is a serious medical emergency that requires prompt diagnosis and treatment to avoid loss of vision and intracranial complications, such as venous thrombosis and empyema.³

Imaging Studies

Although the clinical features of orbital cellulitis (eg, proptosis, ophthalmoplegia, pain with ocular movement) can sometimes distinguish it from preseptal cellulitis, imaging studies are helpful to confirm the diagnosis.⁴ As previously noted, prompt recognition, diagnosis, and treatment of orbital cellulitis are essential to avoid serious complications.

Computed tomography has a high specificity and sensitivity in detecting the extension of infection into the orbit and associated complications such as subperiosteal or intracranial abscess. For patients in whom intravenous (IV) contrast is contraindicated or who wish to avoid ionizing radiation, magnetic resonance imaging is a useful alternate modality, and diffusion-weighted imaging is particularly sensitive in diagnosing abscess.⁵

Treatment

Since polymicrobial infection is common in periorbital cellulitis, broad-spectrum IV antibiotics (eg, ampicillin-sulbactam, cefuroxime, ceftriaxone, piperacillin/tazobactam) are usually indicated initially.⁶ The patient in this case was given IV ceftriaxone and clindamycin and oral amoxicillin/clavulanic acid for 3 days, after which he was discharged home in the care of his parents with instructions to complete a 14-day total course of oral amoxicillin/clavulanic acid as well as a 21-day course of fluticasone for nasal irrigation.

Case

A 3-year-old boy was brought to the ED by his parents for evaluation of left periorbital swelling. A few days prior to presentation, the child was seen at an outpatient center where he was diagnosed with preseptal cellulitis and given an oral antibiotic. However, even after receiving three doses of the antibiotic, the periorbital swelling and redness around the child’s eye worsened, prompting this visit to the ED.

Physical examination revealed edema and erythema both above and below the left eye, with associated tenderness to palpation. A contrast-enhanced maxillofacial computed tomography (CT) scan, with special attention to the orbits, was ordered; representative images are shown (Figure 1a-1c).

What is the diagnosis?

Answer

The CT images of the orbits demonstrated edema in the superficial left eyelid (white arrows, Figure 2a and 2b) and left deep orbital septum (red arrows, Figure 2a-2c). A peripherally enhancing fluid collection centered in the left nasolacrimal gland was present (red asterisks, Figure 2b and 2c) with mild mass effect on the left globe. Opacification was also noted within the paranasal sinuses (white asterisks, Figure 2a-2c). Together these findings indicated sinusitis with dacryocystitis and orbital cellulitis.

Dacryocystitis

Dacryocystitis is an infection or inflammation of the lacrimal sac, usually developing secondary to blockage of the nasolacrimal duct. Orbital cellulitis is an infection involving the contents of the orbit, including the fat and ocular muscles. Orbital cellulitis should not be confused with preseptal cellulitis, which is an infection involving the eyelid occurring posterior to the orbital septum. While both of these conditions are more common in children than in adults, preseptal cellulitis is much more common than orbital cellulitis.

Preseptal Cellulitis

Preseptal cellulitis is typically due to local trauma, local skin infection, or dacryocystitis.¹ Preseptal cellulitis rarely extends into the orbit, though a minority of cases have been reported in patients with concomitant dacryocystitis.² Orbital cellulitis most commonly results from paranasal sinus disease, particularly of the ethmoid sinus, which is only separated from the orbit by the thin lamina papyracea.³ While both preseptal cellulitis and orbital cellulitis can cause eyelid swelling and erythema, preseptal cellulitis is typically a mild condition. Orbital cellulitis, however, is a serious medical emergency that requires prompt diagnosis and treatment to avoid loss of vision and intracranial complications, such as venous thrombosis and empyema.³

Imaging Studies

Although the clinical features of orbital cellulitis (eg, proptosis, ophthalmoplegia, pain with ocular movement) can sometimes distinguish it from preseptal cellulitis, imaging studies are helpful to confirm the diagnosis.⁴ As previously noted, prompt recognition, diagnosis, and treatment of orbital cellulitis are essential to avoid serious complications.

Computed tomography has a high specificity and sensitivity in detecting the extension of infection into the orbit and associated complications such as subperiosteal or intracranial abscess. For patients in whom intravenous (IV) contrast is contraindicated or who wish to avoid ionizing radiation, magnetic resonance imaging is a useful alternate modality, and diffusion-weighted imaging is particularly sensitive in diagnosing abscess.⁵

Treatment

Since polymicrobial infection is common in periorbital cellulitis, broad-spectrum IV antibiotics (eg, ampicillin-sulbactam, cefuroxime, ceftriaxone, piperacillin/tazobactam) are usually indicated initially.⁶ The patient in this case was given IV ceftriaxone and clindamycin and oral amoxicillin/clavulanic acid for 3 days, after which he was discharged home in the care of his parents with instructions to complete a 14-day total course of oral amoxicillin/clavulanic acid as well as a 21-day course of fluticasone for nasal irrigation.

A 32-year-old man presented to the ED with acute onset of left testicular swelling and pain. He described the pain as severe, radiating to his lower back and lower abdomen. Regarding his medical history, the patient stated he had experienced similar episodes of significant testicular swelling in the past, for which he was treated with antibiotics.

Physical examination revealed mild enlargement of the left testis with tenderness to palpation. The right testis was normal in appearance and nontender. An ultrasound study of the testicles was ordered; representative images are shown (Figures 1a-1c).

What is the diagnosis?

The transverse image of both testes demonstrated an enlarged left testicle compared to the right testicle (Figure 2a). On color-flow Doppler ultrasound, spots of color within the testicle were noted within the right testicle only. The lack of blood flow was confirmed on the sagittal image of the left testicle, which also revealed a small hydrocele (white arrows, Figure 2b). A sagittal color Doppler image of the normal right testicle showed color flow (white arrows, Figure 2c) and normal vascular waveforms (red arrow, Figure 2c) within the testis, but no hydrocele, confirming the diagnosis of left testicular torsion. The Doppler ultrasound of the right testicle (white arrows, Figure 2c) further confirmed a normal right testicle but no evidence of flow in the left testicle. These findings were further consistent with the presence of left testicular torsion.

Answer

Testicular Torsion

Testicular torsion is a urological emergency that results from a twisting of the spermatic cord, cutting off arterial flow to, and venous drainage from, the affected testis. There are two types of testicular torsion depending on which side of the tunica vaginalis (the serous membrane pouch covering the testes) the torsion occurs: extra vaginal, seen mainly in newborns; and intravaginal, which can occur at any age, but is more common in adolescents.

“Bell clapper deformity” is a predisposing congenital condition resulting from intravaginal torsion of the testis in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate.¹ Testicular torsion most commonly occurs in young males, with an estimated incidence of 4.5 cases per 100,000 patients between ages 1 and 25 years.²

Clinical Presentation

Patients with testicular torsion typically experience a sudden onset of severe unilateral pain often accompanied by nausea and vomiting, which can occur spontaneously or after vigorous physical activity or trauma. Associated complaints may include urinary symptoms and/or fever.³ The affected testis may lie transversely in the scrotum and be retracted, although physical examination is often nonspecific and unreliable. Since an absence of the cremasteric reflex is neither sensitive nor specific in determining the need for surgical intervention, further diagnostic testing is required.⁴

Doppler Ultrasound

Ultrasound utilizing color and spectral Doppler techniques is the imaging test of choice to evaluate for testicular torsion, and has a reported sensitivity of 82% to 89%, and a specificity of 98% to 100%.^5,6 Ultrasound findings include enlargement and decreased echogenicity of the affected testicle due to edema. Scrotal wall thickening and a small hydrocele also may be seen. Doppler imaging also typically demonstrates absence of flow, though hyperemia and increased flow may be present early in the disease process.

It is important to note that torsion may be intermittent; therefore, imaging studies can appear normal during periods of intermittent perfusion. If there is incomplete torsion and some arterial flow persists in the affected testis, comparison of the two testes using transverse views is very useful in making the diagnosis.⁷

With respect to the differential diagnoses, ultrasound imaging studies are also useful in diagnosing other conditions associated with testicular pain, including torsion of the appendix testis, epididymitis, orchitis, trauma, varicocele, and tumors.

Treatment

Rapid diagnosis of testicular torsion is important, as delay in diagnosis may lead to irreversible damage and loss of the testicle. Infertility can result even with a normal contralateral testis.⁸ When surgical intervention is performed within 6 hours from onset of torsion, salvage of the testicle has been reported to be 90% to 100%, but only 50% and 10% at 12 and 24 hours, respectively.³ The patient in this case was taken immediately for emergent surgical detorsion, and the left testicle was salvaged.

A 32-year-old man presented to the ED with acute onset of left testicular swelling and pain. He described the pain as severe, radiating to his lower back and lower abdomen. Regarding his medical history, the patient stated he had experienced similar episodes of significant testicular swelling in the past, for which he was treated with antibiotics.

Physical examination revealed mild enlargement of the left testis with tenderness to palpation. The right testis was normal in appearance and nontender. An ultrasound study of the testicles was ordered; representative images are shown (Figures 1a-1c).

What is the diagnosis?

The transverse image of both testes demonstrated an enlarged left testicle compared to the right testicle (Figure 2a). On color-flow Doppler ultrasound, spots of color within the testicle were noted within the right testicle only. The lack of blood flow was confirmed on the sagittal image of the left testicle, which also revealed a small hydrocele (white arrows, Figure 2b). A sagittal color Doppler image of the normal right testicle showed color flow (white arrows, Figure 2c) and normal vascular waveforms (red arrow, Figure 2c) within the testis, but no hydrocele, confirming the diagnosis of left testicular torsion. The Doppler ultrasound of the right testicle (white arrows, Figure 2c) further confirmed a normal right testicle but no evidence of flow in the left testicle. These findings were further consistent with the presence of left testicular torsion.

Answer

Testicular Torsion

Testicular torsion is a urological emergency that results from a twisting of the spermatic cord, cutting off arterial flow to, and venous drainage from, the affected testis. There are two types of testicular torsion depending on which side of the tunica vaginalis (the serous membrane pouch covering the testes) the torsion occurs: extra vaginal, seen mainly in newborns; and intravaginal, which can occur at any age, but is more common in adolescents.

“Bell clapper deformity” is a predisposing congenital condition resulting from intravaginal torsion of the testis in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate.¹ Testicular torsion most commonly occurs in young males, with an estimated incidence of 4.5 cases per 100,000 patients between ages 1 and 25 years.²

Clinical Presentation

Patients with testicular torsion typically experience a sudden onset of severe unilateral pain often accompanied by nausea and vomiting, which can occur spontaneously or after vigorous physical activity or trauma. Associated complaints may include urinary symptoms and/or fever.³ The affected testis may lie transversely in the scrotum and be retracted, although physical examination is often nonspecific and unreliable. Since an absence of the cremasteric reflex is neither sensitive nor specific in determining the need for surgical intervention, further diagnostic testing is required.⁴

Doppler Ultrasound

Ultrasound utilizing color and spectral Doppler techniques is the imaging test of choice to evaluate for testicular torsion, and has a reported sensitivity of 82% to 89%, and a specificity of 98% to 100%.^5,6 Ultrasound findings include enlargement and decreased echogenicity of the affected testicle due to edema. Scrotal wall thickening and a small hydrocele also may be seen. Doppler imaging also typically demonstrates absence of flow, though hyperemia and increased flow may be present early in the disease process.

It is important to note that torsion may be intermittent; therefore, imaging studies can appear normal during periods of intermittent perfusion. If there is incomplete torsion and some arterial flow persists in the affected testis, comparison of the two testes using transverse views is very useful in making the diagnosis.⁷

With respect to the differential diagnoses, ultrasound imaging studies are also useful in diagnosing other conditions associated with testicular pain, including torsion of the appendix testis, epididymitis, orchitis, trauma, varicocele, and tumors.

Treatment

Rapid diagnosis of testicular torsion is important, as delay in diagnosis may lead to irreversible damage and loss of the testicle. Infertility can result even with a normal contralateral testis.⁸ When surgical intervention is performed within 6 hours from onset of torsion, salvage of the testicle has been reported to be 90% to 100%, but only 50% and 10% at 12 and 24 hours, respectively.³ The patient in this case was taken immediately for emergent surgical detorsion, and the left testicle was salvaged.

A 32-year-old man presented to the ED with acute onset of left testicular swelling and pain. He described the pain as severe, radiating to his lower back and lower abdomen. Regarding his medical history, the patient stated he had experienced similar episodes of significant testicular swelling in the past, for which he was treated with antibiotics.

Physical examination revealed mild enlargement of the left testis with tenderness to palpation. The right testis was normal in appearance and nontender. An ultrasound study of the testicles was ordered; representative images are shown (Figures 1a-1c).

What is the diagnosis?

The transverse image of both testes demonstrated an enlarged left testicle compared to the right testicle (Figure 2a). On color-flow Doppler ultrasound, spots of color within the testicle were noted within the right testicle only. The lack of blood flow was confirmed on the sagittal image of the left testicle, which also revealed a small hydrocele (white arrows, Figure 2b). A sagittal color Doppler image of the normal right testicle showed color flow (white arrows, Figure 2c) and normal vascular waveforms (red arrow, Figure 2c) within the testis, but no hydrocele, confirming the diagnosis of left testicular torsion. The Doppler ultrasound of the right testicle (white arrows, Figure 2c) further confirmed a normal right testicle but no evidence of flow in the left testicle. These findings were further consistent with the presence of left testicular torsion.

Answer

Testicular Torsion

Testicular torsion is a urological emergency that results from a twisting of the spermatic cord, cutting off arterial flow to, and venous drainage from, the affected testis. There are two types of testicular torsion depending on which side of the tunica vaginalis (the serous membrane pouch covering the testes) the torsion occurs: extra vaginal, seen mainly in newborns; and intravaginal, which can occur at any age, but is more common in adolescents.

“Bell clapper deformity” is a predisposing congenital condition resulting from intravaginal torsion of the testis in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate.¹ Testicular torsion most commonly occurs in young males, with an estimated incidence of 4.5 cases per 100,000 patients between ages 1 and 25 years.²

Clinical Presentation

Patients with testicular torsion typically experience a sudden onset of severe unilateral pain often accompanied by nausea and vomiting, which can occur spontaneously or after vigorous physical activity or trauma. Associated complaints may include urinary symptoms and/or fever.³ The affected testis may lie transversely in the scrotum and be retracted, although physical examination is often nonspecific and unreliable. Since an absence of the cremasteric reflex is neither sensitive nor specific in determining the need for surgical intervention, further diagnostic testing is required.⁴

Doppler Ultrasound

Ultrasound utilizing color and spectral Doppler techniques is the imaging test of choice to evaluate for testicular torsion, and has a reported sensitivity of 82% to 89%, and a specificity of 98% to 100%.^5,6 Ultrasound findings include enlargement and decreased echogenicity of the affected testicle due to edema. Scrotal wall thickening and a small hydrocele also may be seen. Doppler imaging also typically demonstrates absence of flow, though hyperemia and increased flow may be present early in the disease process.

It is important to note that torsion may be intermittent; therefore, imaging studies can appear normal during periods of intermittent perfusion. If there is incomplete torsion and some arterial flow persists in the affected testis, comparison of the two testes using transverse views is very useful in making the diagnosis.⁷

With respect to the differential diagnoses, ultrasound imaging studies are also useful in diagnosing other conditions associated with testicular pain, including torsion of the appendix testis, epididymitis, orchitis, trauma, varicocele, and tumors.

Treatment

Rapid diagnosis of testicular torsion is important, as delay in diagnosis may lead to irreversible damage and loss of the testicle. Infertility can result even with a normal contralateral testis.⁸ When surgical intervention is performed within 6 hours from onset of torsion, salvage of the testicle has been reported to be 90% to 100%, but only 50% and 10% at 12 and 24 hours, respectively.³ The patient in this case was taken immediately for emergent surgical detorsion, and the left testicle was salvaged.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

Laboratory studies revealed leukocytosis with a left shift. Chest radiographs were negative for pneumonia. A magnetic resonance image (MRI) of the lumbar spine was obtained to evaluate for diskitis osteomyelitis. A radiograph of the pelvis was also obtained to evaluate the patient’s THAs, and a computed tomography scan (CT) of the abdomen and pelvis with contrast was obtained for further evaluation. Representative CT, radiographic, and MRI images are shown at left (Figures 1-3).

What is the suspected diagnosis?

Answer

The MRI of the lumbar spine demonstrated no evidence of diskitis osteomyelitis. However, T₂-weighted axial images showed enlarged heterogeneous bilateral psoas muscles with bright signal, indicating the presence of fluid (white arrows, Figure 4).

On the pelvic radiographs, both femoral heads appeared off-center within the acetabular cups (red arrows, Figure 5). This eccentric positioning indicated wear of the polyethylene in the THAs that normally occupies the space between the acetabular cup and the femoral head. In addition, focal lucency in the right acetabulum indicated breakdown of the bone, a condition referred to as osteolysis (white asterisk, Figure 5).

An abdominopelvic CT scan with contrast was performed and confirmed the findings of polyethylene wear and osteolysis. The CT scan also demonstrated large bilateral hip joint effusions (white arrows, Figure 6), decompressed along distended bilateral iliopsoas bursae (red asterisks, Figure 6), and communicating with the bilateral psoas muscle collections (red arrows, Figure 6).

Osteolysis With Iliopsoas Bursitis

Bursae are fluid-filled sacs lined by synovial tissue located throughout the body to reduce friction at sites of movement between muscles, bones, and tendons. Bursitis develops when these sacs become inflamed and/or infected and fill with fluid. The iliopsoas bursa lies between the anterior capsule of the hip and the psoas tendon, iliacus tendon, and muscle fibers.^1,2 This bursa frequently communicates with the hip joint.^3,4 Iliopsoas bursal distension has been reported following THA in the setting of polyethylene wear,⁵ and aseptic bursitis is a commonly seen incidental finding at the time of revision surgery.⁶

In this patient, long-standing polyethylene-induced synovitis had markedly expanded the hip joints and iliopsoas bursae, eventually resulting in superinfection, which accounted for the patient’s symptoms.

Treatment

Based on the imaging findings, interventional radiology services were contacted. The interventional radiologist drained the bilateral psoas abscesses. Cultures of the fluid were positive for both methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S aureus (MSSA). The patient was admitted to the hospital for treatment of MRSA and MSSA with intravenous antibiotic therapy. He recovered from the infection and was discharged on hospital day 2, with instructions to follow up with an orthopedic surgeon to discuss eventual revision of the bilateral THAs.

Laboratory studies revealed leukocytosis with a left shift. Chest radiographs were negative for pneumonia. A magnetic resonance image (MRI) of the lumbar spine was obtained to evaluate for diskitis osteomyelitis. A radiograph of the pelvis was also obtained to evaluate the patient’s THAs, and a computed tomography scan (CT) of the abdomen and pelvis with contrast was obtained for further evaluation. Representative CT, radiographic, and MRI images are shown at left (Figures 1-3).

What is the suspected diagnosis?

Answer

The MRI of the lumbar spine demonstrated no evidence of diskitis osteomyelitis. However, T₂-weighted axial images showed enlarged heterogeneous bilateral psoas muscles with bright signal, indicating the presence of fluid (white arrows, Figure 4).

On the pelvic radiographs, both femoral heads appeared off-center within the acetabular cups (red arrows, Figure 5). This eccentric positioning indicated wear of the polyethylene in the THAs that normally occupies the space between the acetabular cup and the femoral head. In addition, focal lucency in the right acetabulum indicated breakdown of the bone, a condition referred to as osteolysis (white asterisk, Figure 5).

An abdominopelvic CT scan with contrast was performed and confirmed the findings of polyethylene wear and osteolysis. The CT scan also demonstrated large bilateral hip joint effusions (white arrows, Figure 6), decompressed along distended bilateral iliopsoas bursae (red asterisks, Figure 6), and communicating with the bilateral psoas muscle collections (red arrows, Figure 6).

Osteolysis With Iliopsoas Bursitis

Bursae are fluid-filled sacs lined by synovial tissue located throughout the body to reduce friction at sites of movement between muscles, bones, and tendons. Bursitis develops when these sacs become inflamed and/or infected and fill with fluid. The iliopsoas bursa lies between the anterior capsule of the hip and the psoas tendon, iliacus tendon, and muscle fibers.^1,2 This bursa frequently communicates with the hip joint.^3,4 Iliopsoas bursal distension has been reported following THA in the setting of polyethylene wear,⁵ and aseptic bursitis is a commonly seen incidental finding at the time of revision surgery.⁶

In this patient, long-standing polyethylene-induced synovitis had markedly expanded the hip joints and iliopsoas bursae, eventually resulting in superinfection, which accounted for the patient’s symptoms.

Treatment

Based on the imaging findings, interventional radiology services were contacted. The interventional radiologist drained the bilateral psoas abscesses. Cultures of the fluid were positive for both methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S aureus (MSSA). The patient was admitted to the hospital for treatment of MRSA and MSSA with intravenous antibiotic therapy. He recovered from the infection and was discharged on hospital day 2, with instructions to follow up with an orthopedic surgeon to discuss eventual revision of the bilateral THAs.

Laboratory studies revealed leukocytosis with a left shift. Chest radiographs were negative for pneumonia. A magnetic resonance image (MRI) of the lumbar spine was obtained to evaluate for diskitis osteomyelitis. A radiograph of the pelvis was also obtained to evaluate the patient’s THAs, and a computed tomography scan (CT) of the abdomen and pelvis with contrast was obtained for further evaluation. Representative CT, radiographic, and MRI images are shown at left (Figures 1-3).

What is the suspected diagnosis?

Answer

The MRI of the lumbar spine demonstrated no evidence of diskitis osteomyelitis. However, T₂-weighted axial images showed enlarged heterogeneous bilateral psoas muscles with bright signal, indicating the presence of fluid (white arrows, Figure 4).

On the pelvic radiographs, both femoral heads appeared off-center within the acetabular cups (red arrows, Figure 5). This eccentric positioning indicated wear of the polyethylene in the THAs that normally occupies the space between the acetabular cup and the femoral head. In addition, focal lucency in the right acetabulum indicated breakdown of the bone, a condition referred to as osteolysis (white asterisk, Figure 5).

An abdominopelvic CT scan with contrast was performed and confirmed the findings of polyethylene wear and osteolysis. The CT scan also demonstrated large bilateral hip joint effusions (white arrows, Figure 6), decompressed along distended bilateral iliopsoas bursae (red asterisks, Figure 6), and communicating with the bilateral psoas muscle collections (red arrows, Figure 6).

Osteolysis With Iliopsoas Bursitis

Bursae are fluid-filled sacs lined by synovial tissue located throughout the body to reduce friction at sites of movement between muscles, bones, and tendons. Bursitis develops when these sacs become inflamed and/or infected and fill with fluid. The iliopsoas bursa lies between the anterior capsule of the hip and the psoas tendon, iliacus tendon, and muscle fibers.^1,2 This bursa frequently communicates with the hip joint.^3,4 Iliopsoas bursal distension has been reported following THA in the setting of polyethylene wear,⁵ and aseptic bursitis is a commonly seen incidental finding at the time of revision surgery.⁶

In this patient, long-standing polyethylene-induced synovitis had markedly expanded the hip joints and iliopsoas bursae, eventually resulting in superinfection, which accounted for the patient’s symptoms.

Treatment

Based on the imaging findings, interventional radiology services were contacted. The interventional radiologist drained the bilateral psoas abscesses. Cultures of the fluid were positive for both methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S aureus (MSSA). The patient was admitted to the hospital for treatment of MRSA and MSSA with intravenous antibiotic therapy. He recovered from the infection and was discharged on hospital day 2, with instructions to follow up with an orthopedic surgeon to discuss eventual revision of the bilateral THAs.

A 45-year-old woman with a history of polycystic ovary syndrome presented to the ED for evaluation of acute abdominal pain. The patient’s surgical history was significant for a cesarean delivery 6 months prior to presentation. Abdominal examination revealed a well-healed suprapubic cesarean incision scar, which was tender upon palpation. A computed tomography (CT) scan of the abdomen and pelvis with contrast were ordered; representative images are shown above (Figure 1a-1d).

What is the diagnosis? What are the associated complications and preferred management for this entity?

Answer

The scout image from the CT scan shows multiple dilated loops of small bowel (white arrows, Figure 2a) and only a small amount of air within a decompressed colon (red arrow, Figure 2a). The multiplanar CT image confirmed multiple dilated small bowel loops (white arrows, Figure 2b) and the decompressed large bowel (red arrows, Figure 2b), indicating the presence of a small bowel obstruction. A distal small bowel loop (white arrows, Figure 2c and 2d) was identified in a hernia sac within the walls of the rectus abdominis muscle (red arrows, Figure 2c and 2d). Mesenteric stranding within the hernia sac was suggestive of incarceration (black arrow, Figure 2d). No signs of intestinal ischemia, such as pneumatosis or wall thickening, were present.

An exploratory laparotomy was emergently performed, which confirmed the presence of incarcerated small bowel within the posterior rectus sheath defect without evidence of strangulation. Reduction of small bowel and primary closure of the hernia defect was subsequently performed without complication.

Abdominal Wall Hernias

Abdominal wall hernias are common in the United States, with more than 1 million abdominal wall hernia repairs performed annually.¹ A posterior rectus sheath hernia is a rare type of abdominal wall hernia; the majority are postsurgical (as seen in this patient) or posttraumatic, with only a few reported congenital cases.²

Anatomy

The rectus sheath encloses the rectus abdominis muscle and is composed of the aponeuroses of the transversus abdominis, external oblique, and internal oblique muscles. The aponeuroses form an anterior and posterior sheath, which together serve as a strong barrier against the herniation of abdominal contents, accounting for the rarity of a spontaneous rectus sheath hernia. However, inferior to the umbilicus (below the arcuate line), the posterior rectus sheath is composed primarily of transversalis fascia, which may make this region more susceptible to herniation.³ Additional predisposing factors to herniation include increased muscle weakness and elevated intra-abdominal pressure, such as that which occurs during pregnancy or from ascites.⁴

Clinical Presentation

Like other abdominal wall hernias, the clinical presentation of posterior rectus sheath hernias is nonspecific. Patients may be asymptomatic or may develop abdominal pain, distension, and vomiting as a result of acute complications that necessitate emergent surgery. During history-taking, inquiry into a patient’s surgical history is crucial because it may raise clinical suspicion for an abdominal wall hernia, as was the case in our patient, who recently had a cesarean delivery.

Diagnosis

Because prompt and accurate diagnosis of acute complications of abdominal wall hernias is essential, imaging studies are typically required for diagnosis. Computed tomography is the modality of choice based on its ability to provide superior anatomic detail of the abdominal wall, permitting identification of hernias and differentiating them from other abdominal masses, such as hematomas, abscesses, or tumors. Additionally, CT is able to detect early signs of hernia sac complications, including bowel obstruction, incarceration, and strangulation.⁵

Treatment

Treatment for a posterior rectus sheath hernia is surgical with primary closure being the preferred method. Prosthetic repair may also be performed, particularly when the hernia defect is large, but it has been shown to be associated with an increased risk of intestinal strangulation.³

A 45-year-old woman with a history of polycystic ovary syndrome presented to the ED for evaluation of acute abdominal pain. The patient’s surgical history was significant for a cesarean delivery 6 months prior to presentation. Abdominal examination revealed a well-healed suprapubic cesarean incision scar, which was tender upon palpation. A computed tomography (CT) scan of the abdomen and pelvis with contrast were ordered; representative images are shown above (Figure 1a-1d).

What is the diagnosis? What are the associated complications and preferred management for this entity?

Answer

The scout image from the CT scan shows multiple dilated loops of small bowel (white arrows, Figure 2a) and only a small amount of air within a decompressed colon (red arrow, Figure 2a). The multiplanar CT image confirmed multiple dilated small bowel loops (white arrows, Figure 2b) and the decompressed large bowel (red arrows, Figure 2b), indicating the presence of a small bowel obstruction. A distal small bowel loop (white arrows, Figure 2c and 2d) was identified in a hernia sac within the walls of the rectus abdominis muscle (red arrows, Figure 2c and 2d). Mesenteric stranding within the hernia sac was suggestive of incarceration (black arrow, Figure 2d). No signs of intestinal ischemia, such as pneumatosis or wall thickening, were present.

An exploratory laparotomy was emergently performed, which confirmed the presence of incarcerated small bowel within the posterior rectus sheath defect without evidence of strangulation. Reduction of small bowel and primary closure of the hernia defect was subsequently performed without complication.

Abdominal Wall Hernias

Abdominal wall hernias are common in the United States, with more than 1 million abdominal wall hernia repairs performed annually.¹ A posterior rectus sheath hernia is a rare type of abdominal wall hernia; the majority are postsurgical (as seen in this patient) or posttraumatic, with only a few reported congenital cases.²

Anatomy

The rectus sheath encloses the rectus abdominis muscle and is composed of the aponeuroses of the transversus abdominis, external oblique, and internal oblique muscles. The aponeuroses form an anterior and posterior sheath, which together serve as a strong barrier against the herniation of abdominal contents, accounting for the rarity of a spontaneous rectus sheath hernia. However, inferior to the umbilicus (below the arcuate line), the posterior rectus sheath is composed primarily of transversalis fascia, which may make this region more susceptible to herniation.³ Additional predisposing factors to herniation include increased muscle weakness and elevated intra-abdominal pressure, such as that which occurs during pregnancy or from ascites.⁴

Clinical Presentation

Like other abdominal wall hernias, the clinical presentation of posterior rectus sheath hernias is nonspecific. Patients may be asymptomatic or may develop abdominal pain, distension, and vomiting as a result of acute complications that necessitate emergent surgery. During history-taking, inquiry into a patient’s surgical history is crucial because it may raise clinical suspicion for an abdominal wall hernia, as was the case in our patient, who recently had a cesarean delivery.

Diagnosis

Because prompt and accurate diagnosis of acute complications of abdominal wall hernias is essential, imaging studies are typically required for diagnosis. Computed tomography is the modality of choice based on its ability to provide superior anatomic detail of the abdominal wall, permitting identification of hernias and differentiating them from other abdominal masses, such as hematomas, abscesses, or tumors. Additionally, CT is able to detect early signs of hernia sac complications, including bowel obstruction, incarceration, and strangulation.⁵

Treatment

Treatment for a posterior rectus sheath hernia is surgical with primary closure being the preferred method. Prosthetic repair may also be performed, particularly when the hernia defect is large, but it has been shown to be associated with an increased risk of intestinal strangulation.³

A 45-year-old woman with a history of polycystic ovary syndrome presented to the ED for evaluation of acute abdominal pain. The patient’s surgical history was significant for a cesarean delivery 6 months prior to presentation. Abdominal examination revealed a well-healed suprapubic cesarean incision scar, which was tender upon palpation. A computed tomography (CT) scan of the abdomen and pelvis with contrast were ordered; representative images are shown above (Figure 1a-1d).

What is the diagnosis? What are the associated complications and preferred management for this entity?

Answer

The scout image from the CT scan shows multiple dilated loops of small bowel (white arrows, Figure 2a) and only a small amount of air within a decompressed colon (red arrow, Figure 2a). The multiplanar CT image confirmed multiple dilated small bowel loops (white arrows, Figure 2b) and the decompressed large bowel (red arrows, Figure 2b), indicating the presence of a small bowel obstruction. A distal small bowel loop (white arrows, Figure 2c and 2d) was identified in a hernia sac within the walls of the rectus abdominis muscle (red arrows, Figure 2c and 2d). Mesenteric stranding within the hernia sac was suggestive of incarceration (black arrow, Figure 2d). No signs of intestinal ischemia, such as pneumatosis or wall thickening, were present.

An exploratory laparotomy was emergently performed, which confirmed the presence of incarcerated small bowel within the posterior rectus sheath defect without evidence of strangulation. Reduction of small bowel and primary closure of the hernia defect was subsequently performed without complication.

Abdominal Wall Hernias

Abdominal wall hernias are common in the United States, with more than 1 million abdominal wall hernia repairs performed annually.¹ A posterior rectus sheath hernia is a rare type of abdominal wall hernia; the majority are postsurgical (as seen in this patient) or posttraumatic, with only a few reported congenital cases.²

Anatomy

The rectus sheath encloses the rectus abdominis muscle and is composed of the aponeuroses of the transversus abdominis, external oblique, and internal oblique muscles. The aponeuroses form an anterior and posterior sheath, which together serve as a strong barrier against the herniation of abdominal contents, accounting for the rarity of a spontaneous rectus sheath hernia. However, inferior to the umbilicus (below the arcuate line), the posterior rectus sheath is composed primarily of transversalis fascia, which may make this region more susceptible to herniation.³ Additional predisposing factors to herniation include increased muscle weakness and elevated intra-abdominal pressure, such as that which occurs during pregnancy or from ascites.⁴

Clinical Presentation

Like other abdominal wall hernias, the clinical presentation of posterior rectus sheath hernias is nonspecific. Patients may be asymptomatic or may develop abdominal pain, distension, and vomiting as a result of acute complications that necessitate emergent surgery. During history-taking, inquiry into a patient’s surgical history is crucial because it may raise clinical suspicion for an abdominal wall hernia, as was the case in our patient, who recently had a cesarean delivery.

Diagnosis

Because prompt and accurate diagnosis of acute complications of abdominal wall hernias is essential, imaging studies are typically required for diagnosis. Computed tomography is the modality of choice based on its ability to provide superior anatomic detail of the abdominal wall, permitting identification of hernias and differentiating them from other abdominal masses, such as hematomas, abscesses, or tumors. Additionally, CT is able to detect early signs of hernia sac complications, including bowel obstruction, incarceration, and strangulation.⁵

Treatment

Treatment for a posterior rectus sheath hernia is surgical with primary closure being the preferred method. Prosthetic repair may also be performed, particularly when the hernia defect is large, but it has been shown to be associated with an increased risk of intestinal strangulation.³

A 79-year-old woman presented to the ED with acute shortness of breath. Of note, she had been recently discharged from our hospital after an open reduction and internal fixation of an intertrochanteric fracture of the right hip. The patient’s postoperative course was uncomplicated, and she was discharged home after a brief inpatient stay.

On physical examination, the patient was diaphoretic and tachypneic; oxygen saturation was 68% on room air, but increased to 100% saturation with supplemental oxygen through a nonrebreather mask. Radiographs from the patient’s inpatient hospital stay (Figure 1a) as well as ED visit (Figure 1b) were reviewed; representative images are shown above.
 

What is the diagnosis? What additional imaging tests may be useful to confirm the diagnosis?

Answer

The radiographs taken at the time of the patient’s discharge were normal. The radiograph of the chest obtained in the ED, however, demonstrated a distinct cut-off of the right mainstem bronchus, referred to as a bronchial cut-off sign (white arrow, Figure 2), with a rounded density projecting over the right mainstem bronchus (white asterisk, Figure 2). These radiographic appearances suggested the presence of an aspirated foreign body.

A computed tomography (CT) scan of the chest with contrast was performed to further evaluate the radiographic opacity and to exclude pulmonary embolism (PE), as this patient was at risk for such. The CT scan revealed no evidence of PE but confirmed the diagnosis of an aspirated foreign body. A high-density tablet (black asterisk, Figure 3) was noted to be completely occluding the right mainstem bronchus (white arrow, Figure 3) with resultant mild hyperinflation of the right lung. Upon further questioning, the patient stated that she had choked on a calcium tablet earlier in the day, but thought that the pill had finally “gone down.”

Since aspiration of foreign bodies is far more common in children,^1,2 the diagnosis often is not considered in adults who present with acute onset of shortness of breath. In adults, the most significant predisposing factor to aspiration is alcoholism. However, foreign body aspiration may arise in various clinical scenarios, including in patients with structural abnormalities, in those with neuromuscular disease, and in the postoperative setting. The most common aspirated foreign bodies are food and broken tooth fragments/periodontal devices (eg, periodontal splint).²

Presentation is varied and depends upon the nature and volume of the aspirated foreign body, which may contribute to the airway obstruction or an inflammatory bronchopneumonia. The posterior segment of the upper lobes and the superior segments of the lower lobes are the most commonly involved sites, with the right lung preferentially involved over the left lung.³

The diagnosis of foreign body aspiration begins with an appropriate clinical history. Given our patient’s recent orthopedic surgery, PE was an understandable diagnostic consideration. As with any patient acutely short of breath, radiographs are the initial diagnostic imaging study of choice. An abrupt truncation of a bronchus on radiography suggests obstruction related to a mucous plugging, cancer, or foreign body aspiration. Other findings of foreign body aspiration include segmental/lobar hyperinflation and/or atelectasis.³ In many scenarios, the aspirated foreign body may not be radiodense, which limits the utility and diagnostic accuracy of radiography. Computed tomography improves diagnostic precision and time to diagnosis by directly visualizing the airway lumen and improving visualization of radiolucent objects.⁴

Treatment for obstructive aspiration depends upon the location and nature of the aspirated object. However, bedside bronchoscopy and extraction of the foreign object is the mainstay of treatment, and is how this patient was treated. Rapid diagnosis and treatment is key to alleviating obstruction and preventing potential complications of hemoptysis and infection. 

A 79-year-old woman presented to the ED with acute shortness of breath. Of note, she had been recently discharged from our hospital after an open reduction and internal fixation of an intertrochanteric fracture of the right hip. The patient’s postoperative course was uncomplicated, and she was discharged home after a brief inpatient stay.

On physical examination, the patient was diaphoretic and tachypneic; oxygen saturation was 68% on room air, but increased to 100% saturation with supplemental oxygen through a nonrebreather mask. Radiographs from the patient’s inpatient hospital stay (Figure 1a) as well as ED visit (Figure 1b) were reviewed; representative images are shown above.
 

What is the diagnosis? What additional imaging tests may be useful to confirm the diagnosis?

Answer

The radiographs taken at the time of the patient’s discharge were normal. The radiograph of the chest obtained in the ED, however, demonstrated a distinct cut-off of the right mainstem bronchus, referred to as a bronchial cut-off sign (white arrow, Figure 2), with a rounded density projecting over the right mainstem bronchus (white asterisk, Figure 2). These radiographic appearances suggested the presence of an aspirated foreign body.

A computed tomography (CT) scan of the chest with contrast was performed to further evaluate the radiographic opacity and to exclude pulmonary embolism (PE), as this patient was at risk for such. The CT scan revealed no evidence of PE but confirmed the diagnosis of an aspirated foreign body. A high-density tablet (black asterisk, Figure 3) was noted to be completely occluding the right mainstem bronchus (white arrow, Figure 3) with resultant mild hyperinflation of the right lung. Upon further questioning, the patient stated that she had choked on a calcium tablet earlier in the day, but thought that the pill had finally “gone down.”

Since aspiration of foreign bodies is far more common in children,^1,2 the diagnosis often is not considered in adults who present with acute onset of shortness of breath. In adults, the most significant predisposing factor to aspiration is alcoholism. However, foreign body aspiration may arise in various clinical scenarios, including in patients with structural abnormalities, in those with neuromuscular disease, and in the postoperative setting. The most common aspirated foreign bodies are food and broken tooth fragments/periodontal devices (eg, periodontal splint).²

Presentation is varied and depends upon the nature and volume of the aspirated foreign body, which may contribute to the airway obstruction or an inflammatory bronchopneumonia. The posterior segment of the upper lobes and the superior segments of the lower lobes are the most commonly involved sites, with the right lung preferentially involved over the left lung.³

The diagnosis of foreign body aspiration begins with an appropriate clinical history. Given our patient’s recent orthopedic surgery, PE was an understandable diagnostic consideration. As with any patient acutely short of breath, radiographs are the initial diagnostic imaging study of choice. An abrupt truncation of a bronchus on radiography suggests obstruction related to a mucous plugging, cancer, or foreign body aspiration. Other findings of foreign body aspiration include segmental/lobar hyperinflation and/or atelectasis.³ In many scenarios, the aspirated foreign body may not be radiodense, which limits the utility and diagnostic accuracy of radiography. Computed tomography improves diagnostic precision and time to diagnosis by directly visualizing the airway lumen and improving visualization of radiolucent objects.⁴

Treatment for obstructive aspiration depends upon the location and nature of the aspirated object. However, bedside bronchoscopy and extraction of the foreign object is the mainstay of treatment, and is how this patient was treated. Rapid diagnosis and treatment is key to alleviating obstruction and preventing potential complications of hemoptysis and infection. 

A 79-year-old woman presented to the ED with acute shortness of breath. Of note, she had been recently discharged from our hospital after an open reduction and internal fixation of an intertrochanteric fracture of the right hip. The patient’s postoperative course was uncomplicated, and she was discharged home after a brief inpatient stay.

On physical examination, the patient was diaphoretic and tachypneic; oxygen saturation was 68% on room air, but increased to 100% saturation with supplemental oxygen through a nonrebreather mask. Radiographs from the patient’s inpatient hospital stay (Figure 1a) as well as ED visit (Figure 1b) were reviewed; representative images are shown above.
 

What is the diagnosis? What additional imaging tests may be useful to confirm the diagnosis?

Answer

The radiographs taken at the time of the patient’s discharge were normal. The radiograph of the chest obtained in the ED, however, demonstrated a distinct cut-off of the right mainstem bronchus, referred to as a bronchial cut-off sign (white arrow, Figure 2), with a rounded density projecting over the right mainstem bronchus (white asterisk, Figure 2). These radiographic appearances suggested the presence of an aspirated foreign body.

A computed tomography (CT) scan of the chest with contrast was performed to further evaluate the radiographic opacity and to exclude pulmonary embolism (PE), as this patient was at risk for such. The CT scan revealed no evidence of PE but confirmed the diagnosis of an aspirated foreign body. A high-density tablet (black asterisk, Figure 3) was noted to be completely occluding the right mainstem bronchus (white arrow, Figure 3) with resultant mild hyperinflation of the right lung. Upon further questioning, the patient stated that she had choked on a calcium tablet earlier in the day, but thought that the pill had finally “gone down.”

Since aspiration of foreign bodies is far more common in children,^1,2 the diagnosis often is not considered in adults who present with acute onset of shortness of breath. In adults, the most significant predisposing factor to aspiration is alcoholism. However, foreign body aspiration may arise in various clinical scenarios, including in patients with structural abnormalities, in those with neuromuscular disease, and in the postoperative setting. The most common aspirated foreign bodies are food and broken tooth fragments/periodontal devices (eg, periodontal splint).²

Presentation is varied and depends upon the nature and volume of the aspirated foreign body, which may contribute to the airway obstruction or an inflammatory bronchopneumonia. The posterior segment of the upper lobes and the superior segments of the lower lobes are the most commonly involved sites, with the right lung preferentially involved over the left lung.³

The diagnosis of foreign body aspiration begins with an appropriate clinical history. Given our patient’s recent orthopedic surgery, PE was an understandable diagnostic consideration. As with any patient acutely short of breath, radiographs are the initial diagnostic imaging study of choice. An abrupt truncation of a bronchus on radiography suggests obstruction related to a mucous plugging, cancer, or foreign body aspiration. Other findings of foreign body aspiration include segmental/lobar hyperinflation and/or atelectasis.³ In many scenarios, the aspirated foreign body may not be radiodense, which limits the utility and diagnostic accuracy of radiography. Computed tomography improves diagnostic precision and time to diagnosis by directly visualizing the airway lumen and improving visualization of radiolucent objects.⁴

Treatment for obstructive aspiration depends upon the location and nature of the aspirated object. However, bedside bronchoscopy and extraction of the foreign object is the mainstay of treatment, and is how this patient was treated. Rapid diagnosis and treatment is key to alleviating obstruction and preventing potential complications of hemoptysis and infection. 

A 55-year-old man presented with a 2-day history of acute first toe pain in his right foot after banging the affected toe on a door. Physical examination demonstrated a swollen first toe with marked tenderness to palpation. Radiographs were obtained (Figures 1a and 1b).

What is the diagnosis? What additional imaging tests may be useful to confirm the diagnosis?

Answer

The radiographs of the right foot excluded fracture as the underlying etiology of the patient’s pain. The findings included soft tissue swelling and periarticular (ie, near but not involving the joint) erosions involving the first metatarsal head (white asterisks, Figure 1c). The erosion on the medial aspect of the metatarsal head had remodeling of bone at the periphery of the erosion, which created the appearance of “overhanging edges” (white arrows, Figure 1c). The radiographic appearance suggests the diagnosis of gouty arthritis.

Gouty arthritis, which is caused by the deposition of monosodium urate crystals in the soft tissues surrounding joints, continues to increase in prevalence—likely due to the growing aging population and risk factors such as obesity and diabetes. Gouty arthritis typically presents as painful episodes of arthritis affecting a single joint that can be extremely tender to touch. Acute attacks typically subside within 5 to 7 days. Acute gout may result in fever and elevated white blood cell counts, making it difficult to distinguish from septic arthritis.¹ While more common in males in the younger population, gout affects men and women equally in patients older than age 60 years.²

While patients with gouty arthritis have hyperuricemia, only approximately 10% develop gout. The American College of Rheumatology’s preliminary criteria² for the diagnosis of gout include the presence of characteristic urate crystals in the joint fluid of the affected joint during the attack, the presence of a tophus (soft tissue mass containing urate crystals), or at least six of the following:

• More than one attack of acute arthritis
• Maximum joint inflammation developed within 1 day
• Monoarticular arthritis
• Redness of the joint
• First metatarsophalangeal (MTP) joint pain/swelling
• Unilateral first MTP joint attack
• Unilateral tarsal joint attack
• Suspected tophus
• Hyperuricemia
• Asymmetrical swelling of the joint on radiography
• Subcortical cysts without erosions on radiography
• Joint fluid culture negative during an attack.

As highlighted by the criteria, the first MTP joint is a common location for gouty arthritis, and is referred to as podagra. A meta-analysis published in 2016 reports that an estimated 73% of patients with gout will have involvement of the first MTP.³

Regarding imaging studies, radiography is often the first imaging test performed to evaluate for gout, and can reveal characteristic findings such as periarticular erosions with sclerotic margins, overhanging edges of remodeling bone, and adjacent soft tissue tophi. These findings, however, occur late in the disease. Ultrasound may be useful for earlier diagnosis with the “double contour sign,” which is a specific finding representing the appearance of urate crystals deposited on the hyaline cartilage of the joint. Dual-energy computed tomography (CT) has been shown to not only demonstrate early erosions and soft tissue tophi, but also to characterize the crystals, making CT a highly sensitive and specific test for the detection of gouty arthritis.⁴

Treatment of acute episodes of gout includes nonsteroidal anti-inflammatory agents, colchicine, and corticosteroids. Early diagnosis and treatment can prevent progression to advanced arthritis and chronic impairment.

A 55-year-old man presented with a 2-day history of acute first toe pain in his right foot after banging the affected toe on a door. Physical examination demonstrated a swollen first toe with marked tenderness to palpation. Radiographs were obtained (Figures 1a and 1b).

What is the diagnosis? What additional imaging tests may be useful to confirm the diagnosis?

Answer

The radiographs of the right foot excluded fracture as the underlying etiology of the patient’s pain. The findings included soft tissue swelling and periarticular (ie, near but not involving the joint) erosions involving the first metatarsal head (white asterisks, Figure 1c). The erosion on the medial aspect of the metatarsal head had remodeling of bone at the periphery of the erosion, which created the appearance of “overhanging edges” (white arrows, Figure 1c). The radiographic appearance suggests the diagnosis of gouty arthritis.

Gouty arthritis, which is caused by the deposition of monosodium urate crystals in the soft tissues surrounding joints, continues to increase in prevalence—likely due to the growing aging population and risk factors such as obesity and diabetes. Gouty arthritis typically presents as painful episodes of arthritis affecting a single joint that can be extremely tender to touch. Acute attacks typically subside within 5 to 7 days. Acute gout may result in fever and elevated white blood cell counts, making it difficult to distinguish from septic arthritis.¹ While more common in males in the younger population, gout affects men and women equally in patients older than age 60 years.²

While patients with gouty arthritis have hyperuricemia, only approximately 10% develop gout. The American College of Rheumatology’s preliminary criteria² for the diagnosis of gout include the presence of characteristic urate crystals in the joint fluid of the affected joint during the attack, the presence of a tophus (soft tissue mass containing urate crystals), or at least six of the following:

• More than one attack of acute arthritis
• Maximum joint inflammation developed within 1 day
• Monoarticular arthritis
• Redness of the joint
• First metatarsophalangeal (MTP) joint pain/swelling
• Unilateral first MTP joint attack
• Unilateral tarsal joint attack
• Suspected tophus
• Hyperuricemia
• Asymmetrical swelling of the joint on radiography
• Subcortical cysts without erosions on radiography
• Joint fluid culture negative during an attack.

As highlighted by the criteria, the first MTP joint is a common location for gouty arthritis, and is referred to as podagra. A meta-analysis published in 2016 reports that an estimated 73% of patients with gout will have involvement of the first MTP.³

Regarding imaging studies, radiography is often the first imaging test performed to evaluate for gout, and can reveal characteristic findings such as periarticular erosions with sclerotic margins, overhanging edges of remodeling bone, and adjacent soft tissue tophi. These findings, however, occur late in the disease. Ultrasound may be useful for earlier diagnosis with the “double contour sign,” which is a specific finding representing the appearance of urate crystals deposited on the hyaline cartilage of the joint. Dual-energy computed tomography (CT) has been shown to not only demonstrate early erosions and soft tissue tophi, but also to characterize the crystals, making CT a highly sensitive and specific test for the detection of gouty arthritis.⁴

Treatment of acute episodes of gout includes nonsteroidal anti-inflammatory agents, colchicine, and corticosteroids. Early diagnosis and treatment can prevent progression to advanced arthritis and chronic impairment.

A 55-year-old man presented with a 2-day history of acute first toe pain in his right foot after banging the affected toe on a door. Physical examination demonstrated a swollen first toe with marked tenderness to palpation. Radiographs were obtained (Figures 1a and 1b).

What is the diagnosis? What additional imaging tests may be useful to confirm the diagnosis?

Answer

The radiographs of the right foot excluded fracture as the underlying etiology of the patient’s pain. The findings included soft tissue swelling and periarticular (ie, near but not involving the joint) erosions involving the first metatarsal head (white asterisks, Figure 1c). The erosion on the medial aspect of the metatarsal head had remodeling of bone at the periphery of the erosion, which created the appearance of “overhanging edges” (white arrows, Figure 1c). The radiographic appearance suggests the diagnosis of gouty arthritis.

Gouty arthritis, which is caused by the deposition of monosodium urate crystals in the soft tissues surrounding joints, continues to increase in prevalence—likely due to the growing aging population and risk factors such as obesity and diabetes. Gouty arthritis typically presents as painful episodes of arthritis affecting a single joint that can be extremely tender to touch. Acute attacks typically subside within 5 to 7 days. Acute gout may result in fever and elevated white blood cell counts, making it difficult to distinguish from septic arthritis.¹ While more common in males in the younger population, gout affects men and women equally in patients older than age 60 years.²

While patients with gouty arthritis have hyperuricemia, only approximately 10% develop gout. The American College of Rheumatology’s preliminary criteria² for the diagnosis of gout include the presence of characteristic urate crystals in the joint fluid of the affected joint during the attack, the presence of a tophus (soft tissue mass containing urate crystals), or at least six of the following:

• More than one attack of acute arthritis
• Maximum joint inflammation developed within 1 day
• Monoarticular arthritis
• Redness of the joint
• First metatarsophalangeal (MTP) joint pain/swelling
• Unilateral first MTP joint attack
• Unilateral tarsal joint attack
• Suspected tophus
• Hyperuricemia
• Asymmetrical swelling of the joint on radiography
• Subcortical cysts without erosions on radiography
• Joint fluid culture negative during an attack.

As highlighted by the criteria, the first MTP joint is a common location for gouty arthritis, and is referred to as podagra. A meta-analysis published in 2016 reports that an estimated 73% of patients with gout will have involvement of the first MTP.³

Regarding imaging studies, radiography is often the first imaging test performed to evaluate for gout, and can reveal characteristic findings such as periarticular erosions with sclerotic margins, overhanging edges of remodeling bone, and adjacent soft tissue tophi. These findings, however, occur late in the disease. Ultrasound may be useful for earlier diagnosis with the “double contour sign,” which is a specific finding representing the appearance of urate crystals deposited on the hyaline cartilage of the joint. Dual-energy computed tomography (CT) has been shown to not only demonstrate early erosions and soft tissue tophi, but also to characterize the crystals, making CT a highly sensitive and specific test for the detection of gouty arthritis.⁴

Treatment of acute episodes of gout includes nonsteroidal anti-inflammatory agents, colchicine, and corticosteroids. Early diagnosis and treatment can prevent progression to advanced arthritis and chronic impairment.