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X-Ray Goes Knee Deep
Answer
The radiograph shows evidence of status post arthroplasty. There are no abnormalities within the prosthesis. However, the patient has a fracture of the proximal tibia that extends into the tibial plateau, as well as a nondisplaced fracture of the proximal fibula.
The patient was admitted and orthopedics consulted.
Answer
The radiograph shows evidence of status post arthroplasty. There are no abnormalities within the prosthesis. However, the patient has a fracture of the proximal tibia that extends into the tibial plateau, as well as a nondisplaced fracture of the proximal fibula.
The patient was admitted and orthopedics consulted.
Answer
The radiograph shows evidence of status post arthroplasty. There are no abnormalities within the prosthesis. However, the patient has a fracture of the proximal tibia that extends into the tibial plateau, as well as a nondisplaced fracture of the proximal fibula.
The patient was admitted and orthopedics consulted.
Is It More Than a Cold?
ANSWER
The radiograph does not demonstrate any evidence of infiltrate or pleural effusion. However, of note is a rather large lytic lesion involving the posterior aspect of the right fourth rib. This finding is very concerning for either a primary bone neoplasm or (more likely) a metastatic one.
The patient denied any history of cancer. She was promptly referred to Hematology/Oncology for further evaluation and workup. At last update, she had undergone a bone marrow biopsy, with preliminary pathology results suggestive of a plasma cell neoplasm.
ANSWER
The radiograph does not demonstrate any evidence of infiltrate or pleural effusion. However, of note is a rather large lytic lesion involving the posterior aspect of the right fourth rib. This finding is very concerning for either a primary bone neoplasm or (more likely) a metastatic one.
The patient denied any history of cancer. She was promptly referred to Hematology/Oncology for further evaluation and workup. At last update, she had undergone a bone marrow biopsy, with preliminary pathology results suggestive of a plasma cell neoplasm.
ANSWER
The radiograph does not demonstrate any evidence of infiltrate or pleural effusion. However, of note is a rather large lytic lesion involving the posterior aspect of the right fourth rib. This finding is very concerning for either a primary bone neoplasm or (more likely) a metastatic one.
The patient denied any history of cancer. She was promptly referred to Hematology/Oncology for further evaluation and workup. At last update, she had undergone a bone marrow biopsy, with preliminary pathology results suggestive of a plasma cell neoplasm.
A 70-year-old woman presents to the urgent care clinic with a week-long history of cold and cough that she feels is getting worse. She reports subjective fever and chills, as well as an occasional pain in the right side of her chest when she breathes. She has been taking OTC products with limited relief.
Her medical history is significant for mild hypertension. She denies smoking. On physical exam, you note an elderly female in no obvious distress. She is afebrile, with normal vital signs. Pulse oximetry reveals an O2 saturation of 98% on room air. Auscultation of her lungs demonstrates a little bit of mid bronchial congestion and perhaps some bibasilar crackles.
You order a complete blood count as well as a chest radiograph (shown). What is your impression?
Diagnosis Is an Open Book
ANSWER
There is evidence of significant widening of the pubic symphysis. This injury results in a disruption of the normal pelvic ring. Such fractures are typically referred to as open-book pelvic fractures. Usually the result of high-energy trauma, they can also be associated with bladder and/or vascular injuries.
Orthopedics was consulted for management of this injury. Prompt stabilization with an external binder may help reduce complications. The patient will ultimately require some form of external or internal fixation.
ANSWER
There is evidence of significant widening of the pubic symphysis. This injury results in a disruption of the normal pelvic ring. Such fractures are typically referred to as open-book pelvic fractures. Usually the result of high-energy trauma, they can also be associated with bladder and/or vascular injuries.
Orthopedics was consulted for management of this injury. Prompt stabilization with an external binder may help reduce complications. The patient will ultimately require some form of external or internal fixation.
ANSWER
There is evidence of significant widening of the pubic symphysis. This injury results in a disruption of the normal pelvic ring. Such fractures are typically referred to as open-book pelvic fractures. Usually the result of high-energy trauma, they can also be associated with bladder and/or vascular injuries.
Orthopedics was consulted for management of this injury. Prompt stabilization with an external binder may help reduce complications. The patient will ultimately require some form of external or internal fixation.
A 50-year-old woman is airlifted to your facility from the scene of an accident. She was riding a motorcycle that was struck by a car at a presumed high rate of speed. There was reportedly a brief loss of consciousness, although when the first responders arrived, the patient was complaining of pain in both her hands and wrists, as well as severe hip pain.
The patient was hemodynamically stable during transport. Blood pressure on arrival is 130/78 mm Hg, with a heart rate of 90 beats/min. Her O2 saturation is 97% with supplemental oxygen administered by nasal cannula.
As you begin your primary survey, the patient responds appropriately to you: She tells you her name and where she is from. Her medical history is significant for migraines, and her surgical history is significant for a prior cholecystectomy and tubal ligation. Primary exam overall appears normal, except for obvious deformities in both wrists.
As you begin your secondary survey, the radiology technicians obtain portable chest and pelvis radiographs (latter shown). What is your impression?
Cross at the Green, Not in Between
ANSWER
Aside from the usual artifacts from placement on a backboard and from the presence of monitoring devices and wires, the radiograph shows a displaced fracture of the right clavicle. No other significant abnormalities are present.
The patient was ultimately diagnosed with multiple orthopedic injuries, and orthopedics was called to evaluate and manage accordingly.
ANSWER
Aside from the usual artifacts from placement on a backboard and from the presence of monitoring devices and wires, the radiograph shows a displaced fracture of the right clavicle. No other significant abnormalities are present.
The patient was ultimately diagnosed with multiple orthopedic injuries, and orthopedics was called to evaluate and manage accordingly.
ANSWER
Aside from the usual artifacts from placement on a backboard and from the presence of monitoring devices and wires, the radiograph shows a displaced fracture of the right clavicle. No other significant abnormalities are present.
The patient was ultimately diagnosed with multiple orthopedic injuries, and orthopedics was called to evaluate and manage accordingly.
A 25-year-old man is brought to your facility by EMS transport following an accident while riding a bicycle. Witnesses say he was hit by a car when he suddenly tried to cross a busy intersection. They also report that he was not wearing a helmet and that he was thrown off the bike, landing several feet away.
Initial survey reveals a male who is arousable but nonverbal, just moaning and groaning. There are obvious deformities in both lower extremities and the right upper extremity. The patient’s blood pressure is 100/50 mm Hg and his heart rate, 130 beats/min. Pulse oximetry shows his O2 saturation to be 95% with 100% oxygen via nonrebreather mask. His pupils are equal and reactive bilaterally. Heart and lungs sound clear. Abdomen is soft.
While you continue examining the patient and begin your secondary survey, a portable chest radiograph is obtained (shown). What is your impression?
Is Diagnosis Up in the Air?
ANSWER
The radiograph shows 3 abnormalities:
(1) The endotracheal tube is in the right mainstem bronchus—a finding that in part leads to
(2) A whiteout of the left lung; the latter is due partly to collapse and atelectasis and partly to a possible pneumothorax.
(3) There is evidence of free air under the left hemidiaphragm, which is concerning for an intra-abdominal injury, such as a perforated viscus.
The patient’s endotracheal tube was partially withdrawn, and a left chest tube was placed. Subsequent CT of the abdomen confirmed the finding of free air. She was then taken to the operating room for an emergent laparotomy.
ANSWER
The radiograph shows 3 abnormalities:
(1) The endotracheal tube is in the right mainstem bronchus—a finding that in part leads to
(2) A whiteout of the left lung; the latter is due partly to collapse and atelectasis and partly to a possible pneumothorax.
(3) There is evidence of free air under the left hemidiaphragm, which is concerning for an intra-abdominal injury, such as a perforated viscus.
The patient’s endotracheal tube was partially withdrawn, and a left chest tube was placed. Subsequent CT of the abdomen confirmed the finding of free air. She was then taken to the operating room for an emergent laparotomy.
ANSWER
The radiograph shows 3 abnormalities:
(1) The endotracheal tube is in the right mainstem bronchus—a finding that in part leads to
(2) A whiteout of the left lung; the latter is due partly to collapse and atelectasis and partly to a possible pneumothorax.
(3) There is evidence of free air under the left hemidiaphragm, which is concerning for an intra-abdominal injury, such as a perforated viscus.
The patient’s endotracheal tube was partially withdrawn, and a left chest tube was placed. Subsequent CT of the abdomen confirmed the finding of free air. She was then taken to the operating room for an emergent laparotomy.
An air ambulance emergently transports a young woman from the scene of a motor vehicle collision to your facility. The details of the accident and age of the patient are unknown. The air ambulance crew had intubated her en route for a decreased level of responsiveness and for airway protection.
The patient is brought to your trauma bay, where you note an intubated female teenager who is unresponsive, with a Glasgow Coma Sc
Her pupils are equal and react bilaterally, albeit sluggishly. Her right leg was placed in an immobilizer by the air ambulance crew because they had noted a right thigh deformity.
Before completing your primary survey, you obtain a portable chest radiograph (shown). What is your impression?
There’s Mischief Afoot
ANSWER
The radiograph demonstrates no evidence of an acute fracture or soft-tissue gas to suggest an abscess. Of note, though, within the tibiotalar joint, the patient has bony destruction and settling of the articular surfaces of both the distal tibia and fibula into the talus and calcaneus.
This finding is typically associated with neuropathic arthropathy (also known as a Charcot joint). This pathologic process is typically seen in a weight-bearing joint that develops progressive degeneration from chronic loss of sensation.
ANSWER
The radiograph demonstrates no evidence of an acute fracture or soft-tissue gas to suggest an abscess. Of note, though, within the tibiotalar joint, the patient has bony destruction and settling of the articular surfaces of both the distal tibia and fibula into the talus and calcaneus.
This finding is typically associated with neuropathic arthropathy (also known as a Charcot joint). This pathologic process is typically seen in a weight-bearing joint that develops progressive degeneration from chronic loss of sensation.
ANSWER
The radiograph demonstrates no evidence of an acute fracture or soft-tissue gas to suggest an abscess. Of note, though, within the tibiotalar joint, the patient has bony destruction and settling of the articular surfaces of both the distal tibia and fibula into the talus and calcaneus.
This finding is typically associated with neuropathic arthropathy (also known as a Charcot joint). This pathologic process is typically seen in a weight-bearing joint that develops progressive degeneration from chronic loss of sensation.
A 70-year-old man presents for evaluation of left foot pain, redness, and swelling. He reports injuring the foot a week ago; he went to the emergency department for evaluation of the cut he had sustained, which required stapling.
The patient has a chronic foot ulcer for which a home health aide provides wound care and dressing changes. His medical history is significant for hypertension, stroke with chronic left-sided weakness, congestive heart failure, and chronic renal insufficiency. He admits to daily tobacco use, and his medical record reflects a history of drug use.
On physical exam, you note an elderly, chronically ill male in no obvious distress. His vital signs are stable, and he is afebrile. Inspection of his left foot shows generalized swelling and redness. Good distal pulses are appreciated. On the dorsal aspect, there is a healing wound with a single staple present. On the heel is a 2-cm stage 2 ulcer with some scant purulent drainage.
Bloodwork and a radiograph of the left foot are ordered; lateral view is shown. What is your impression?
These Hips Don’t Lie
ANSWER
The radiograph shows no evidence of an acute fracture. Incidental findings include excreted contrast within the bladder and radiopaque markers from prostatic seed implants.
Fairly extensive sclerosis is noted within both femoral heads, which is suggestive of osteonecrosis (also known as avascular necrosis). Orthopedic consult was requested for further workup of this specific problem.
ANSWER
The radiograph shows no evidence of an acute fracture. Incidental findings include excreted contrast within the bladder and radiopaque markers from prostatic seed implants.
Fairly extensive sclerosis is noted within both femoral heads, which is suggestive of osteonecrosis (also known as avascular necrosis). Orthopedic consult was requested for further workup of this specific problem.
ANSWER
The radiograph shows no evidence of an acute fracture. Incidental findings include excreted contrast within the bladder and radiopaque markers from prostatic seed implants.
Fairly extensive sclerosis is noted within both femoral heads, which is suggestive of osteonecrosis (also known as avascular necrosis). Orthopedic consult was requested for further workup of this specific problem.
An 80-year-old man is transferred to your facility for evaluation of a lumbar compression fracture he sustained from a motor vehicle collision. The patient was a restrained driver in a vehicle that was broadsided at an unknown speed. His airbags deployed. In addition to mild back discomfort, he complains of severe right hip pain.
His medical history is significant for prostate cancer and coronary artery disease. Surgical history includes remote cardiac bypass surgery and recent revascularization with stents.
On examination, you note an elderly male who is awake and alert. His vital signs are stable. He is able to move all extremities
A portable pelvis radiograph is obtained (shown). What is your impression?
Give Her a Shoulder to Cry on
ANSWER
The radiograph demonstrates an acute horizontal fracture through the humeral neck. There is some slight lateral displacement of the fracture fragment.
The patient’s right arm was placed in a sling. Prompt orthopedic consultation was then obtained.
ANSWER
The radiograph demonstrates an acute horizontal fracture through the humeral neck. There is some slight lateral displacement of the fracture fragment.
The patient’s right arm was placed in a sling. Prompt orthopedic consultation was then obtained.
ANSWER
The radiograph demonstrates an acute horizontal fracture through the humeral neck. There is some slight lateral displacement of the fracture fragment.
The patient’s right arm was placed in a sling. Prompt orthopedic consultation was then obtained.
After a motor vehicle collision, a 70-year-old woman is brought to your emergency department by EMS personnel. She was a restrained driver in a vehicle crossing an intersection when she was broadsided by a tractor trailer traveling at high speed. Her airbags deployed, and she believes she briefly lost consciousness. Her biggest complaint is pain in her right shoulder.
Her medical history is significant for hypertension and hypothyroidism. On primary survey, you note an elderly woman who is in full cervical spine immobilization on a long backboard. Her Glasgow Coma Scale score is 15. She is in mild distress but has normal vital signs.
The patient has scattered abrasions and bruises on her body. Her right shoulder has mild to moderate tenderness to palpation and a decreased range of motion. Distally in that arm, she has good pulses and is neurovascularly intact.
You obtain a portable radiograph of the right shoulder (shown). What is your impression?
More Than His Car Is Bent Out of Shape
ANSWER
The radiograph demonstrates bilateral hip dislocations. On the right, the femoral head appears to be posteriorly dislocated and slightly internally rotated. On the left, the femoral head appears to be anteriorly and superiorly dislocated (although evaluation is limited by a single view). Neither side appears to have any obvious fractures.
The patient’s dislocations were promptly reduced in the trauma bay by the orthopedic service before he was sent for CT.
ANSWER
The radiograph demonstrates bilateral hip dislocations. On the right, the femoral head appears to be posteriorly dislocated and slightly internally rotated. On the left, the femoral head appears to be anteriorly and superiorly dislocated (although evaluation is limited by a single view). Neither side appears to have any obvious fractures.
The patient’s dislocations were promptly reduced in the trauma bay by the orthopedic service before he was sent for CT.
ANSWER
The radiograph demonstrates bilateral hip dislocations. On the right, the femoral head appears to be posteriorly dislocated and slightly internally rotated. On the left, the femoral head appears to be anteriorly and superiorly dislocated (although evaluation is limited by a single view). Neither side appears to have any obvious fractures.
The patient’s dislocations were promptly reduced in the trauma bay by the orthopedic service before he was sent for CT.
A 30-year-old man is broug
Upon arrival, he is immediately intubated because emergency personnel had difficulty intubating him in the field. He has a Glasgow Coma Scale score of 3T. The patient’s blood pressure is 90/40 mm Hg and his heart rate, 150 beats/min. He appears to have deformities in his lower extremities.
You obtain portable radiographs of the chest and pelvis. The latter is shown. What is your impression?
After a Need for Speed, a Spine Entwined?
ANSWER
The radiograph demonstrates a comminuted fracture of the superior end plate of L1. There is a loss of height of about 20% to 25%.
Of note, there is a lucency that appears to extend horizontally through the pedicles and into the spinous process. If this observation is accurate, then the patient would have a three-column injury. Such fractures are known as Chance fractures, and they are typically unstable and require operative intervention for stabilization.
Chance fractures are better visualized on CT. Subsequent testing
ANSWER
The radiograph demonstrates a comminuted fracture of the superior end plate of L1. There is a loss of height of about 20% to 25%.
Of note, there is a lucency that appears to extend horizontally through the pedicles and into the spinous process. If this observation is accurate, then the patient would have a three-column injury. Such fractures are known as Chance fractures, and they are typically unstable and require operative intervention for stabilization.
Chance fractures are better visualized on CT. Subsequent testing
ANSWER
The radiograph demonstrates a comminuted fracture of the superior end plate of L1. There is a loss of height of about 20% to 25%.
Of note, there is a lucency that appears to extend horizontally through the pedicles and into the spinous process. If this observation is accurate, then the patient would have a three-column injury. Such fractures are known as Chance fractures, and they are typically unstable and require operative intervention for stabilization.
Chance fractures are better visualized on CT. Subsequent testing
A 28-year-old man is brought to your emergency department via ambulance after a motor vehicle accident. The patient was a restrained driver who was driving too fast, lost control, and ended up in a ditch. His vehicle then rolled over several times. He reportedly self-extricated and was ambulatory at the scene.
His primary complaints include left shoulder, chest wall, and back pain. He denies any significant medical history.
On physical examination, you note a man with normal vital signs who, although slightly anxious, is in no obvious distress. He has moderate tenderness over the left shoulder and sternum and at the thoracolumbar juncture. No step-offs are appreciated. He is able to move all extremities and is neurovascularly intact.
As you await lab results, you obtain a lateral radiograph of the lumbar spine (shown). What is your impression?
