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Driver Partially Ejected From Vehicle
ANSWER
The radiograph shows that the distal femur is medially dislocated relative to the tibial plateau. In addition, the patella is laterally dislocated. No obvious fractures are evident.
Such injuries are typically associated with significant ligament injuries, especially of the medial collateral ligament (MCL), lateral collateral ligament (LCL), and anterior cruciate ligament (ACL). Orthopedics was consulted for reduction of the dislocation, as well as further workup (including MRI of the knee).
ANSWER
The radiograph shows that the distal femur is medially dislocated relative to the tibial plateau. In addition, the patella is laterally dislocated. No obvious fractures are evident.
Such injuries are typically associated with significant ligament injuries, especially of the medial collateral ligament (MCL), lateral collateral ligament (LCL), and anterior cruciate ligament (ACL). Orthopedics was consulted for reduction of the dislocation, as well as further workup (including MRI of the knee).
ANSWER
The radiograph shows that the distal femur is medially dislocated relative to the tibial plateau. In addition, the patella is laterally dislocated. No obvious fractures are evident.
Such injuries are typically associated with significant ligament injuries, especially of the medial collateral ligament (MCL), lateral collateral ligament (LCL), and anterior cruciate ligament (ACL). Orthopedics was consulted for reduction of the dislocation, as well as further workup (including MRI of the knee).
A 28-year-old man is brought to your facility by EMS for evaluation status post a motor vehicle accident. The patient was an unrestrained driver in a truck that went off the road into a ditch. The paramedics state that he was partially ejected, with his left leg caught in the window. There was brief loss of consciousness. Upon arrival, he is awake and alert, with a Glasgow Coma Scale score of 15. His primary complaints are of back and left leg pain. His medical history is unremarkable, and vital signs are stable. Primary survey shows no obvious injury. Secondary survey reveals moderate swelling and decreased range of motion in the left knee. Good distal pulses are present. As part of your orders, you request a portable radiograph of the left knee. What is your impression?
Woman Complains of Knee Pain Following Fight
ANSWER
The radiograph shows a small calcification along the medial aspect of the medial collateral ligament. This finding is known as a Pellegrini-Stieda lesion. While it certainly could represent a small avulsion fracture, the lack of joint fluid and soft-tissue swelling makes this diagnosis less likely. The patient was treated symptomatically with anti-inflammatory medications.
ANSWER
The radiograph shows a small calcification along the medial aspect of the medial collateral ligament. This finding is known as a Pellegrini-Stieda lesion. While it certainly could represent a small avulsion fracture, the lack of joint fluid and soft-tissue swelling makes this diagnosis less likely. The patient was treated symptomatically with anti-inflammatory medications.
ANSWER
The radiograph shows a small calcification along the medial aspect of the medial collateral ligament. This finding is known as a Pellegrini-Stieda lesion. While it certainly could represent a small avulsion fracture, the lack of joint fluid and soft-tissue swelling makes this diagnosis less likely. The patient was treated symptomatically with anti-inflammatory medications.
A 35-year-old woman presents for evaluation of left knee pain secondary to an assault. She says she was involved in a fight and was struck multiple times throughout her whole body. She states she is “sore all over,” but her knee bothers her the most, as it is difficult and painful to bear weight. The patient’s medical history is unremarkable. Physical exam shows a young female who is uncomfortable but in no obvious distress. Her vital signs are normal. You note bruises throughout her body. Inspection of her left knee shows no obvious deformity or swelling. There is some mild bruising and pain present to palpation. She has limited flexion and extension secondary to pain. However, the joint itself appears stable. Radiographs of the knee are obtained. What is your impression?
Seizure Prompts Man to Fall
ANSWER
The radiograph shows a fracture dislocation of the ankle. The distal tibia is dislocated medially relative to the talus, as evidenced by the widened joint space. There is also an oblique fracture of the distal fibula.
Since the patient was experiencing neurovascular compromise, the dislocation was promptly reduced in the emergency department. Subsequently, he was taken to the operating room for open reduction and internal fixation of his fibula fracture.
ANSWER
The radiograph shows a fracture dislocation of the ankle. The distal tibia is dislocated medially relative to the talus, as evidenced by the widened joint space. There is also an oblique fracture of the distal fibula.
Since the patient was experiencing neurovascular compromise, the dislocation was promptly reduced in the emergency department. Subsequently, he was taken to the operating room for open reduction and internal fixation of his fibula fracture.
ANSWER
The radiograph shows a fracture dislocation of the ankle. The distal tibia is dislocated medially relative to the talus, as evidenced by the widened joint space. There is also an oblique fracture of the distal fibula.
Since the patient was experiencing neurovascular compromise, the dislocation was promptly reduced in the emergency department. Subsequently, he was taken to the operating room for open reduction and internal fixation of his fibula fracture.
A 70-year-old man is brought to your facility by EMS following a new-onset, witnessed seizure. He reportedly fell down some steps. On arrival, he has returned to baseline but is complaining of left-sided weakness and right ankle pain. Medical history is significant for mild hypertension. Vital signs are stable. The patient exhibits slight confusion. He reports some mild weakness on his left side, especially in his lower extremity. There also appears to be moderate soft-tissue swelling of his right ankle, with a slight deformity noted. Dorsalis pedal pulse appears to be slightly diminished in that foot as well. You send the patient for noncontrast CT of the head, as well as a radiograph of the right ankle (the latter of which is shown). What is your impression?
Postoperative Patient Suddenly Worsens
ANSWER
The radiograph demonstrates bilateral elevated diaphragm with a moderate amount of visible free air. With no history of recent abdominal procedures, the primary concern is a perforated viscus.
Urgent surgical consultation, as well as CT of the abdomen and pelvis, was obtained. The imaging confirmed the free air but provided no clear etiology. The patient underwent emergent laparotomy later that day and was found to have a perforated colon.
ANSWER
The radiograph demonstrates bilateral elevated diaphragm with a moderate amount of visible free air. With no history of recent abdominal procedures, the primary concern is a perforated viscus.
Urgent surgical consultation, as well as CT of the abdomen and pelvis, was obtained. The imaging confirmed the free air but provided no clear etiology. The patient underwent emergent laparotomy later that day and was found to have a perforated colon.
ANSWER
The radiograph demonstrates bilateral elevated diaphragm with a moderate amount of visible free air. With no history of recent abdominal procedures, the primary concern is a perforated viscus.
Urgent surgical consultation, as well as CT of the abdomen and pelvis, was obtained. The imaging confirmed the free air but provided no clear etiology. The patient underwent emergent laparotomy later that day and was found to have a perforated colon.
A 55-year-old man undergoes an elective craniotomy for tumor resection, with uneventful preoperative and intraoperative stages. Immediately postoperative, however, he experiences seizures. Noncontrast CT of the head is negative except for postoperative changes. The patient is placed in the ICU for close monitoring. He is slowly improving when, on the fifth postoperative day, tachypnea and dyspnea are observed. The patient is afebrile. His blood pressure is 116/70 mm Hg; pulse, 90 beats/min; respiratory rate, 30 breaths/min; and O2 saturation, 98%. A stat portable chest radiograph is obtained. What is your impression?
An Incidental Finding During Neuro Evaluation
ANSWER
The radiograph shows a normal-appearing chest. Of note, though, is an anterior dislocation of the right shoulder. In addition, there is a fracture within the greater tuberosity of the right humerus.
Prompt orthopedic evaluation is obtained. In further discussion with the family, it was revealed that the patient had been experiencing falls recently; this injury was most likely the result of one.
ANSWER
The radiograph shows a normal-appearing chest. Of note, though, is an anterior dislocation of the right shoulder. In addition, there is a fracture within the greater tuberosity of the right humerus.
Prompt orthopedic evaluation is obtained. In further discussion with the family, it was revealed that the patient had been experiencing falls recently; this injury was most likely the result of one.
ANSWER
The radiograph shows a normal-appearing chest. Of note, though, is an anterior dislocation of the right shoulder. In addition, there is a fracture within the greater tuberosity of the right humerus.
Prompt orthopedic evaluation is obtained. In further discussion with the family, it was revealed that the patient had been experiencing falls recently; this injury was most likely the result of one.
A 65-year-old woman is transferred to your facility from an outlying hospital for evaluation of a brain tumor. Family members found the patient sitting on the sofa, with a decreased level of consciousness. There was reported “seizure-type activity.” When she arrived at the outlying hospital, the patient was noted to have right-side weakness. Stat CT of the head demonstrated a fairly large parasagittal mass, and the patient was urgently transferred to your facility for neurosurgical evaluation. Primary survey on arrival shows an older female who is awake, alert, and in no obvious distress. Vital signs are normal. She has fairly pronounced right upper extremity weakness, more proximally than distally. Otherwise, the exam grossly appears normal. The patient’s initial imaging studies were sent with her on a CD. As you are trying to view the images of the brain, a chest radiograph pops up on your screen. What is your impression?
Left Arm Pain, Numbness, and Weakness
ANSWER
The radiograph shows no evidence of a fracture. However, there is a 2-cm focal sclerotic area noted within the juncture of the humeral neck and head. This finding could represent an enchondroma, a bone cyst, or a bone infarct. Additional imaging, including MRI and bone scan, is warranted, as is orthopedic evaluation. This finding is likely incidental, as the patient’s clinical exam is suggestive of a cervical radiculitis referable to the herniated disc in her neck.
ANSWER
The radiograph shows no evidence of a fracture. However, there is a 2-cm focal sclerotic area noted within the juncture of the humeral neck and head. This finding could represent an enchondroma, a bone cyst, or a bone infarct. Additional imaging, including MRI and bone scan, is warranted, as is orthopedic evaluation. This finding is likely incidental, as the patient’s clinical exam is suggestive of a cervical radiculitis referable to the herniated disc in her neck.
ANSWER
The radiograph shows no evidence of a fracture. However, there is a 2-cm focal sclerotic area noted within the juncture of the humeral neck and head. This finding could represent an enchondroma, a bone cyst, or a bone infarct. Additional imaging, including MRI and bone scan, is warranted, as is orthopedic evaluation. This finding is likely incidental, as the patient’s clinical exam is suggestive of a cervical radiculitis referable to the herniated disc in her neck.
A 40-year-old woman presents to the urgent care clinic complaining of left arm pain with associated numbness and weakness. She denies any injury or trauma, adding that the pain manifested several months ago but has recently progressed. She has already undergone outpatient MRI of her neck; she was told she had some “herniated discs” and would need to see a specialist. Her medical history is significant for hypertension. On physical examination, the patient appears uncomfortable but in no obvious distress. Vital signs are normal. Tenderness is present at the left trapezius and the left shoulder. Mild weakness is present in the left arm; strength is 4/5 and grip strength, 3/5. Pulses are normal, and sensation is intact. Available medical records include a report from her recent MRI of the cervical spine. Findings include a moderate left-sided disc osteophyte at the C6-C7 level and resultant cervical stenosis. A radiograph of the left shoulder is obtained. What is your impression?
Man Unresponsive After Being Struck by Car
ANSWER
The radiograph demonstrates bilateral patchy, fluffy infiltrates as well as what is sometimes referred to as ground-glass opacities. In the setting of trauma and respiratory compromise, these areas are most suggestive of pulmonary contusions and early acute respiratory distress syndrome. Other possibilities in the differential diagnosis include pulmonary edema, atypical pneumonia, and pulmonary metastases.
ANSWER
The radiograph demonstrates bilateral patchy, fluffy infiltrates as well as what is sometimes referred to as ground-glass opacities. In the setting of trauma and respiratory compromise, these areas are most suggestive of pulmonary contusions and early acute respiratory distress syndrome. Other possibilities in the differential diagnosis include pulmonary edema, atypical pneumonia, and pulmonary metastases.
ANSWER
The radiograph demonstrates bilateral patchy, fluffy infiltrates as well as what is sometimes referred to as ground-glass opacities. In the setting of trauma and respiratory compromise, these areas are most suggestive of pulmonary contusions and early acute respiratory distress syndrome. Other possibilities in the differential diagnosis include pulmonary edema, atypical pneumonia, and pulmonary metastases.
A 50-year-old man is transferred to your facility from an outlying community hospital. He is purportedly a pedestrian who was struck by a car. EMS personnel reported him to be unresponsive at the scene. He was intubated for airway protection and stabilized at the outside facility prior to transfer. Upon arrival at your facility, he is still intubated and unresponsive, and his Glasgow Coma Scale score is 3T. His heart rate is 150 beats/min and his blood pressure, 105/56 mm Hg. No additional history is available. Primary survey reveals a large scalp laceration with currently controlled bleeding. His pupils are nonreactive bilaterally. The patient is tachycardic with bilateral crackles. He also has a laceration and deformity of his right lower extremity. No imaging was provided in the transfer, so you obtain a portable chest radiograph. What is your impression?
More to the Story Than a Skull Fracture
ANSWER
The radiograph shows two areas of concern: Within the apex of the right lung, there is a vague haziness that, in the setting of trauma, is suggestive of a contusion or even aspiration pneumonia. Another possibility is some sort of neoplasm. In addition, the patient has what appears to be a rounded density within the left lung, also suspicious for neoplasm. Additional work-up with contrast-enhanced CT is warranted.
Through further questioning, the patient denies any current symptoms or previous/recent diagnosis of cancer. CT of the chest confirmed the presence of masses in the right upper and left lower lobes. Subsequent biopsy was consistent with a moderate to poorly differentiated squamous cell carcinoma.
ANSWER
The radiograph shows two areas of concern: Within the apex of the right lung, there is a vague haziness that, in the setting of trauma, is suggestive of a contusion or even aspiration pneumonia. Another possibility is some sort of neoplasm. In addition, the patient has what appears to be a rounded density within the left lung, also suspicious for neoplasm. Additional work-up with contrast-enhanced CT is warranted.
Through further questioning, the patient denies any current symptoms or previous/recent diagnosis of cancer. CT of the chest confirmed the presence of masses in the right upper and left lower lobes. Subsequent biopsy was consistent with a moderate to poorly differentiated squamous cell carcinoma.
ANSWER
The radiograph shows two areas of concern: Within the apex of the right lung, there is a vague haziness that, in the setting of trauma, is suggestive of a contusion or even aspiration pneumonia. Another possibility is some sort of neoplasm. In addition, the patient has what appears to be a rounded density within the left lung, also suspicious for neoplasm. Additional work-up with contrast-enhanced CT is warranted.
Through further questioning, the patient denies any current symptoms or previous/recent diagnosis of cancer. CT of the chest confirmed the presence of masses in the right upper and left lower lobes. Subsequent biopsy was consistent with a moderate to poorly differentiated squamous cell carcinoma.
A 63-year-old man is transferred to your facility with a skull fracture secondary to a fall. He thinks he tripped and fell, hitting his head. He does not recall experiencing dizziness or syncope. He states he was momentarily dazed but does not think he lost consciousness. He is complaining of a mild headache and has reported drainage from his left ear. He denies any noteworthy medical history and takes no medications regularly. He admits to smoking one to one-and-a-half packs of cigarettes per day. Initial assessment reveals an older-appearing male who is awake, alert, oriented, and in no obvious distress. His vital signs, including O2 saturation, are normal. His pupils are equal and react briskly. He does have obvious otorrhea from his left ear. He is moving all his extremities well and appears to have no deficits. You review his imaging studies, which include a chest radiograph (shown). What is your impression?
Confusion Follows Malaise and Pain
ANSWER
The radiograph demonstrates innumerable small lytic defects throughout the calvarium. The patient’s confusion is most likely secondary to profound metabolic abnormalities. However, in the setting of lytic bone lesions, metabolic abnormalities of renal insufficiency, severe hypercalcemia, and hypomagnesemia, one must be concerned about an occult myeloma, and appropriate work-up must be done.
ANSWER
The radiograph demonstrates innumerable small lytic defects throughout the calvarium. The patient’s confusion is most likely secondary to profound metabolic abnormalities. However, in the setting of lytic bone lesions, metabolic abnormalities of renal insufficiency, severe hypercalcemia, and hypomagnesemia, one must be concerned about an occult myeloma, and appropriate work-up must be done.
ANSWER
The radiograph demonstrates innumerable small lytic defects throughout the calvarium. The patient’s confusion is most likely secondary to profound metabolic abnormalities. However, in the setting of lytic bone lesions, metabolic abnormalities of renal insufficiency, severe hypercalcemia, and hypomagnesemia, one must be concerned about an occult myeloma, and appropriate work-up must be done.
A 70-year-old woman is brought to the emergency department by her family for evaluation of acute altered mental status. According to the family, the patient has been complaining of general malaise, back pain, and severe joint pain for the past few days. Her confusion has increased in the past 24 hours. Medical history is significant for hypertension. Physical exam reveals an elderly female who appears somewhat uncomfortable. Vital signs are normal. Overall, her exam is stable. She has tenderness throughout her back and several of her joints, but no abnormal effusion or swelling is noted. While the patient is in triage, baseline labwork is ordered. The results indicate a serum creatinine of 1.83 mg/dL; serum calcium, 16.7 mg/dL; and serum magnesium, 1.4 mEq/L. Radiograph of the skull is obtained. What is your impression?
Nausea, Vomiting, and Worsening Pain
ANSWER
The radiograph shows multiple stacked dilated loops of small bowel. The colon does not appear distended. (A nasogastric tube is also present, and there are degenerative changes in the spine.) Such a finding is typically associated with at least a partial small bowel obstruction, since no definite air fluid levels are noted.
The patient was admitted and made npo. Nasogastric decompression was started, and general surgery consultation was obtained.
ANSWER
The radiograph shows multiple stacked dilated loops of small bowel. The colon does not appear distended. (A nasogastric tube is also present, and there are degenerative changes in the spine.) Such a finding is typically associated with at least a partial small bowel obstruction, since no definite air fluid levels are noted.
The patient was admitted and made npo. Nasogastric decompression was started, and general surgery consultation was obtained.
ANSWER
The radiograph shows multiple stacked dilated loops of small bowel. The colon does not appear distended. (A nasogastric tube is also present, and there are degenerative changes in the spine.) Such a finding is typically associated with at least a partial small bowel obstruction, since no definite air fluid levels are noted.
The patient was admitted and made npo. Nasogastric decompression was started, and general surgery consultation was obtained.
A 75-year-old woman presents to the emergency department with a three-day history of abdominal pain. She does not recall eating anything unusual. She reports having nausea and vomiting and states that her pain is progressively worsening. Her medical history is significant for hypertension. Surgical history is significant for previous cholecystectomy and total abdominal hysterectomy. She is afebrile, and her vital signs are within normal limits. Her abdomen is soft and diffusely tender, with slightly decreased bowel sounds. No rebound or guarding is present. The rest of her physical examination overall is within normal limits. During the exam, she experiences a couple episodes of bilious vomiting. You order some laboratory studies as well as an abdominal radiograph (shown). What is your impression?
