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Man Thrown From All-Terrain Vehicle
ANSWER
The image shows several things. First, there is a well-corticated lucency through the base of the odontoid process. This most likely represents what is referred to as an os odontoideum (congenital spinal variant). The other possibility is that it could be an old odontoid fracture with nonunion.
In addition, there are superior end-plate fractures noted in C6, C7, T1, and T2. However, no definite fracture lines are evident, suggesting these are subacute or old injuries. MRI can be performed to differentiate old versus new fractures; in this case, it was determined these were old.
ANSWER
The image shows several things. First, there is a well-corticated lucency through the base of the odontoid process. This most likely represents what is referred to as an os odontoideum (congenital spinal variant). The other possibility is that it could be an old odontoid fracture with nonunion.
In addition, there are superior end-plate fractures noted in C6, C7, T1, and T2. However, no definite fracture lines are evident, suggesting these are subacute or old injuries. MRI can be performed to differentiate old versus new fractures; in this case, it was determined these were old.
ANSWER
The image shows several things. First, there is a well-corticated lucency through the base of the odontoid process. This most likely represents what is referred to as an os odontoideum (congenital spinal variant). The other possibility is that it could be an old odontoid fracture with nonunion.
In addition, there are superior end-plate fractures noted in C6, C7, T1, and T2. However, no definite fracture lines are evident, suggesting these are subacute or old injuries. MRI can be performed to differentiate old versus new fractures; in this case, it was determined these were old.
A 57-year-old man is transferred to your facility after being thrown from an all-terrain vehicle. He was not wearing a helmet and was documented to have loss of consciousness. Upon arrival, his primary complaint is severe headache. He gives no significant medical history. Initial assessment shows a male on a backboard with full cervical spine immobilization. His Glasgow Coma Scale score is 14, with a blood pressure of 130/83 mm Hg and a heart rate of 87 beats/min. He has several abrasions on his face, but his pupils are equal and react well. His heart and lungs appear to be clear and the abdomen is benign. He is able to move all extremities well, with no obvious neurovascular compromise. After removal from the backboard, he is sent to the radiology department for multiple scans. A static sagittal image from CT of the cervical spine is shown. What is your impression?
Man Presents with Altered Mental Status and Confusion
ANSWER
The chest radiograph demonstrates a fairly large right hilar mass with an associated right upper lobe infiltrate. This finding is very worrisome for a bronchogenic carcinoma.
Subsequent CT of the brain also demonstrated a right parietal mass. Thus, this lung lesion is most likely a primary neoplasm with metastatic involvement.
ANSWER
The chest radiograph demonstrates a fairly large right hilar mass with an associated right upper lobe infiltrate. This finding is very worrisome for a bronchogenic carcinoma.
Subsequent CT of the brain also demonstrated a right parietal mass. Thus, this lung lesion is most likely a primary neoplasm with metastatic involvement.
ANSWER
The chest radiograph demonstrates a fairly large right hilar mass with an associated right upper lobe infiltrate. This finding is very worrisome for a bronchogenic carcinoma.
Subsequent CT of the brain also demonstrated a right parietal mass. Thus, this lung lesion is most likely a primary neoplasm with metastatic involvement.
A 59-year-old man presents to your facility for evaluation of altered mental status and confusion that have progressively worsened in the past two months. He denies any injury or trauma. He states he has had associated headaches and dizziness. He denies any weight loss, shortness of breath, or malaise; however, he himself is able to notice that his mentation has “not been right.” His medical history is significant for mild hypertension and hyperlipidemia, both of which are well controlled. He discloses a 50–pack-year history of cigarette use. Physical exam reveals a male in no obvious distress but complaining of a moderate headache. His vital signs are stable. His oxygen saturation is 97% on room air. Breath sounds appear clear. The neurologic exam shows no focal deficits. You order noncontrast CT of the head, as well as a chest radiograph. The chest radiograph is shown. What is your impression?
Elderly Man with Headaches and Weakness
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
ANSWER
The chest radiograph demonstrates evidence of previous sternotomy. No evidence of acute infiltrate is noted.
However, there is a prominence within the left hilar region. This finding is strongly suggestive of neoplasm until proven otherwise. The patient was promptly referred for CT of the chest, abdomen, and pelvis, which confirmed the lesion. Subsequent CT-guided biopsy was performed.
A 71-year-old man presents with complaints of headaches and weakness that have been ongoing for almost a month. He denies any fever, nausea, or vomiting. He has noticed an occasional cough and denies any weight loss. The patient has an extensive history of coronary artery disease, hypertension, and hyperlipidemia. History is also significant for coronary artery bypass grafting. He denies any history of smoking. The man is afebrile, and the rest of his vital signs, including pulse oximetry, are within normal limits. Physical exam shows an elderly, ill-appearing man in no obvious distress. Breath sounds bilaterally are clear. You order a chest radiograph along with some bloodwork. The chest radiograph is shown. What is your impression?
Car Accident and a Language Barrier
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
ANSWER
The radiograph shows an obvious deformity in the distal humerus consistent with an old fracture with chronic malunion. There is no evidence of a superimposed acute fracture.
Once family and interpreters became available, it was elicited that the patient, who is originally from Nepal, did sustain a childhood injury and broke his right arm. No acute intervention was required.
You are asked to see a 41-year-old man complaining of right upper arm pain. He was brought in by EMS from a reported single-vehicle crash, in which he was one of approximately 15 people traveling in a van. The patient speaks little to no English, and details of the accident are sketchy. Best as can be ascertained, the vehicle either went out of control or was hit and ran off the road. There were known fatalities at the scene. Due to language barriers, history is limited. Physical exam shows a middle-aged Asian man who appears quite uncomfortable. He indicates he is hurting in his chest, back, and right arm. His vital signs are normal, and primary survey appears stable, with the patient having multiple abrasions on his face and whole body. Examination of his right arm shows multiple abrasions with some bruising and swelling, as well as a deformity just above the elbow. The patient is able to slowly move his wrist and fingers. Distal pulses and sensation appear intact. Radiograph of the right humerus is shown. What is your impression?
Disoriented, Intoxicated, and Hurting All Over
Answer
The radiograph demonstrates a mildly displaced fracture of the right iliac wing. In addition, there is moderate diastasis of the pubic symphysis, with the right pubic symphysis being in superior position to the left. Also, a right sacral fracture is present.
The patient was admitted by the trauma service and initially evaluated by the orthopedic trauma team, who planned to take the patient to surgery for subsequent open reduction and internal fixation of these injuries.
Answer
The radiograph demonstrates a mildly displaced fracture of the right iliac wing. In addition, there is moderate diastasis of the pubic symphysis, with the right pubic symphysis being in superior position to the left. Also, a right sacral fracture is present.
The patient was admitted by the trauma service and initially evaluated by the orthopedic trauma team, who planned to take the patient to surgery for subsequent open reduction and internal fixation of these injuries.
Answer
The radiograph demonstrates a mildly displaced fracture of the right iliac wing. In addition, there is moderate diastasis of the pubic symphysis, with the right pubic symphysis being in superior position to the left. Also, a right sacral fracture is present.
The patient was admitted by the trauma service and initially evaluated by the orthopedic trauma team, who planned to take the patient to surgery for subsequent open reduction and internal fixation of these injuries.
A woman, approximately 30 years old, is airlifted to your facility after being “found in a ditch,” presumably as a result of a motor vehicle collision. Details are sketchy. Upon arrival at your facility, she is awake, crying, and complaining of “hurting all over.” She appears to be intoxicated. She is able to give you her name, but not much else in the way of history. Primary survey shows her vital signs to be: blood pressure, 105/75 mm Hg; heart rate, 102 beats/min; and respiratory rate, 20 breaths/min. She is afebrile. She has a superficial scalp laceration but no other obvious injuries. You obtain preliminary portable radiographs of the pelvis. What is your impression?
Unrestrained Passenger Injured in Car Accident
ANSWER
There is a cortical irregularity at the medial margin of the left iliac bone at the level of the acetabulum, strongly suggestive of a fracture. In addition, there may be a nondisplaced fracture within the superior/inferior rami on the left.
CT was recommended to further define these areas (and was already pending to evaluate the patient’s abdomen). Fortunately, there were no fractures within the hip joint, just the nondisplaced rami fracture.
ANSWER
There is a cortical irregularity at the medial margin of the left iliac bone at the level of the acetabulum, strongly suggestive of a fracture. In addition, there may be a nondisplaced fracture within the superior/inferior rami on the left.
CT was recommended to further define these areas (and was already pending to evaluate the patient’s abdomen). Fortunately, there were no fractures within the hip joint, just the nondisplaced rami fracture.
ANSWER
There is a cortical irregularity at the medial margin of the left iliac bone at the level of the acetabulum, strongly suggestive of a fracture. In addition, there may be a nondisplaced fracture within the superior/inferior rami on the left.
CT was recommended to further define these areas (and was already pending to evaluate the patient’s abdomen). Fortunately, there were no fractures within the hip joint, just the nondisplaced rami fracture.
A 19-year-old man is transferred to your facility for injuries he sustained in a motor vehicle collision. He was an unrestrained passenger in a vehicle that went out of control and left the road. At the outside facility, he was found to have a chest injury and a pneumothorax, resulting in his transfer for tertiary level care. On arrival, he is complaining of some chest wall pain, but also states that his hips—especially the left one—are causing quite a bit of discomfort. His medical history is unremarkable except for sickle cell trait. Primary survey reveals stable vital signs and no obvious injury. On closer examination, with stress on his pelvis, he does complain of localized pain on the left side. Radiograph of the pelvis is obtained. What is your impression?
Woman with Severe Ankle Pain After Fall
ANSWER
There is an obvious oblique fracture of the distal fibula. In addition, there is widening of the mortise medially—usually suggestive of a ligament injury. Also, there may be a small avulsion at the inferior aspect of the medial malleolus.
The patient was admitted with a plan for her to undergo an open reduction and internal fixation procedure.
ANSWER
There is an obvious oblique fracture of the distal fibula. In addition, there is widening of the mortise medially—usually suggestive of a ligament injury. Also, there may be a small avulsion at the inferior aspect of the medial malleolus.
The patient was admitted with a plan for her to undergo an open reduction and internal fixation procedure.
ANSWER
There is an obvious oblique fracture of the distal fibula. In addition, there is widening of the mortise medially—usually suggestive of a ligament injury. Also, there may be a small avulsion at the inferior aspect of the medial malleolus.
The patient was admitted with a plan for her to undergo an open reduction and internal fixation procedure.
A 39-year-old woman presents to your emergency department complaining of right ankle pain following an injury last night. She states that she got out of bed during the night, somehow misstepped, and fell to the floor. She is unable to bear weight on the ankle and is experiencing severe pain. Her medical history is significant for being one month status post Chiari decompression. She also has a history of bipolar disorder. Examination of the patient’s right ankle shows it to be moderately swollen with some bruising laterally. The patient has limited flexion and extension, and her ankle is extremely tender to palpation. Her distal pulses and her sensation are intact. Radiographs of the right ankle are shown. What is your impression?
Shoulder Pain in Man Hospitalized for Brain Mass
ANSWER
There is no evidence of an acute fracture or dislocation. However, there is a focal lytic lesion within the scapula. Given a presumed history of renal cell carcinoma, this finding is strongly suspicious for metastasis and must be worked up.
ANSWER
There is no evidence of an acute fracture or dislocation. However, there is a focal lytic lesion within the scapula. Given a presumed history of renal cell carcinoma, this finding is strongly suspicious for metastasis and must be worked up.
ANSWER
There is no evidence of an acute fracture or dislocation. However, there is a focal lytic lesion within the scapula. Given a presumed history of renal cell carcinoma, this finding is strongly suspicious for metastasis and must be worked up.
A 53-year-old man is admitted with a possible brain mass. He gives a two-week history of headaches and intermittent left-sided weakness. Outpatient CT of the head showed a possible right frontal mass. His medical history is significant for mild hypertension and for the removal of one kidney seven years ago, due to cancer. He states he received no adjuvant therapy. When you check on the patient today, he mentions that his left shoulder has been bothering him for some time. He denies any injury to it. He states he has decreased range of motion and pain with range of motion. You order a radiograph of the shoulder (shown). What is your impression?
Man with Decreasing Consciousness and Increasing Confusion
ANSWER
The radiograph demonstrates a lucency at the base of the odontoid (C2). In addition, there is a slight posterior subluxation of C1 on C2.
Although these findings were deemed likely to be chronic and old in nature, for completeness, an MRI of the cervical spine was obtained. It did, in fact, confirm the findings to be old.
ANSWER
The radiograph demonstrates a lucency at the base of the odontoid (C2). In addition, there is a slight posterior subluxation of C1 on C2.
Although these findings were deemed likely to be chronic and old in nature, for completeness, an MRI of the cervical spine was obtained. It did, in fact, confirm the findings to be old.
ANSWER
The radiograph demonstrates a lucency at the base of the odontoid (C2). In addition, there is a slight posterior subluxation of C1 on C2.
Although these findings were deemed likely to be chronic and old in nature, for completeness, an MRI of the cervical spine was obtained. It did, in fact, confirm the findings to be old.
A 72-year-old nursing home resident is sent for evaluation of decreased level of consciousness, nausea, vomiting, and increasing confusion. He denies any recent injury or trauma. His medical history is significant for diabetes, stroke, dementia, atrial fibrillation, and hypertension. The patient denies any head or neck pain. His vital signs are stable. Overall, aside from reports of occasional confusion, his physical examination is benign. He moves all of his extremities well and appears to have no deficits, including no neck or back tenderness. In reviewing his lab work, you see his sodium concentration is 126 mEq/L. CT of the head shows only chronic changes. Cervical spine radiographs are also obtained; the lateral view is shown. What is your impression?
Severe Injury After Being Struck by a Car
The radiograph reveals several findings. First, there are obvious displaced fractures of the right superior and inferior rami bones. There is also a diastatic fracture of the left sacroiliac joint.
Also, as the bladder is full of contrast (probably from a recent cystogram), note how it appears to be displaced to a more superior position than usual. This is second- ary to formation of a pelvic hematoma.
The radiograph reveals several findings. First, there are obvious displaced fractures of the right superior and inferior rami bones. There is also a diastatic fracture of the left sacroiliac joint.
Also, as the bladder is full of contrast (probably from a recent cystogram), note how it appears to be displaced to a more superior position than usual. This is second- ary to formation of a pelvic hematoma.
The radiograph reveals several findings. First, there are obvious displaced fractures of the right superior and inferior rami bones. There is also a diastatic fracture of the left sacroiliac joint.
Also, as the bladder is full of contrast (probably from a recent cystogram), note how it appears to be displaced to a more superior position than usual. This is second- ary to formation of a pelvic hematoma.
A 59-year-old man was struck by a car while walking. He was initially evaluated at another facility, intubated, resuscitated, and stabilized, then transferred to your facility. He is believed to have a severe head injury and possibly other internal injuries. The man is unresponsive on arrival at your facility. No medical history is available. His vital signs are stable, with a blood pressure of 113/74 mm Hg; heart rate, 101 beats/min; and respiratory rate, 14 breaths/min. Initial Glasgow Coma Scale score is reported as a 3T. It is unclear whether the patient has recently received any sedation. As you are reviewing the results of testing conducted at both your facility and the facility to which the patient was originally taken, you see a portable pelvic radiograph (shown). What is your impression?
