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Elective Craniotomy Results in Respiratory Distress
ANSWER
The radiograph shows complete opacification of the left hemithorax. The differential includes total atelectasis of the lung, mucus plug within the left bronchus, or possible blood or fluid collection. Of note, the patient has a catheter within the left subclavian vein, the distal tip of which appears to be in an unusual location. In this case, it was determined that the displaced catheter tip, resulting in hemothorax, was the etiology. The line was removed, and urgent cardiothoracic consultation was obtained. A left chest tube was promptly placed, with a resultant 2 L of immediate output. The patient improved clinically as well.
ANSWER
The radiograph shows complete opacification of the left hemithorax. The differential includes total atelectasis of the lung, mucus plug within the left bronchus, or possible blood or fluid collection. Of note, the patient has a catheter within the left subclavian vein, the distal tip of which appears to be in an unusual location. In this case, it was determined that the displaced catheter tip, resulting in hemothorax, was the etiology. The line was removed, and urgent cardiothoracic consultation was obtained. A left chest tube was promptly placed, with a resultant 2 L of immediate output. The patient improved clinically as well.
ANSWER
The radiograph shows complete opacification of the left hemithorax. The differential includes total atelectasis of the lung, mucus plug within the left bronchus, or possible blood or fluid collection. Of note, the patient has a catheter within the left subclavian vein, the distal tip of which appears to be in an unusual location. In this case, it was determined that the displaced catheter tip, resulting in hemothorax, was the etiology. The line was removed, and urgent cardiothoracic consultation was obtained. A left chest tube was promptly placed, with a resultant 2 L of immediate output. The patient improved clinically as well.
A 60-year-old woman undergoes an elective craniotomy for clipping of a nonruptured aneurysm. The perioperative course is uneventful, and the aneurysm is clipped without complication. The patient is extubated and sent to the recovery room. Within 30 minutes, you are notified by the nurse that the patient is experiencing moderate respiratory distress. There are no neurologic deficits. Her medical history includes hypertension, hypercholesterolemia, and coronary artery disease, with previous stenting. Preoperative medical and cardiac clearance for the craniotomy had been obtained. Examination reveals the patient to be in a postanesthetic state, with mild-to-moderate dyspnea and tachypnea. She appears to be moving all of her extremities well. Her O2 saturation is 92% on 100% oxygen via a nonrebreather mask. Her breath sounds are significantly diminished on the left side. A stat portable chest radiograph is obtained. What is your impression?
Fall From Trail Leaves Woman in Pain
ANSWER
The radiographs demonstrate a left inferior pubic ramus fracture. The patient was referred to orthopedics for follow-up. She was given a walker and a series of home exercises for hip stretching and strengthening, as well as anti-inflammatories as needed for discomfort. She was scheduled for a four-week follow-up visit and repeat radiographs of the pelvis.
ANSWER
The radiographs demonstrate a left inferior pubic ramus fracture. The patient was referred to orthopedics for follow-up. She was given a walker and a series of home exercises for hip stretching and strengthening, as well as anti-inflammatories as needed for discomfort. She was scheduled for a four-week follow-up visit and repeat radiographs of the pelvis.
ANSWER
The radiographs demonstrate a left inferior pubic ramus fracture. The patient was referred to orthopedics for follow-up. She was given a walker and a series of home exercises for hip stretching and strengthening, as well as anti-inflammatories as needed for discomfort. She was scheduled for a four-week follow-up visit and repeat radiographs of the pelvis.
A 56-year old woman presents for evaluation of left hip pain. Several hours ago, she says, she was walking on a trail when she fell from an embankment. The 4-ft fall ended with her landing primarily on her left hip and elbow. Afterward, she was able to ambulate with assistance but noticed increased pain in her left hip and groin with movement. The elbow discomfort resolved shortly after the incident. She denies numbness or tingling in her extremities and loss of bowel or bladder function. Physical exam reveals a well-developed, well-nourished female without any extremity deformity or leg shortening. Palpation elicits left-sided groin pain, as well as left posterior hip and sacroiliac joint pain. Both active and passive range-of-motion of the hip elicit pain, but straight-leg raise does not. The patient can bear weight on the left leg with the assistance of a walker. There is no laxity in the knee joint, and the ankle mortise is stable. There are no signs of swelling or bruising, and the skin is intact. Dorsalis pedis and posterior tibial pulses are 2+, and sensation in the left foot is intact. Radiographs of the left hip and pelvis are obtained. What is your impression?
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).
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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.
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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.
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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.
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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.
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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?
A Not-So-Old Football Injury
ANSWER
Imaging shows a ventral dislocation of the lunate. There is also a tiny avulsion fracture on the ulnar aspect of the adjacent triquetrum.
The patient was referred to orthopedics for a perilunate dislocation of the left wrist. He underwent successful closed reduction and was placed in a short arm cast for four weeks.
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Imaging shows a ventral dislocation of the lunate. There is also a tiny avulsion fracture on the ulnar aspect of the adjacent triquetrum.
The patient was referred to orthopedics for a perilunate dislocation of the left wrist. He underwent successful closed reduction and was placed in a short arm cast for four weeks.
ANSWER
Imaging shows a ventral dislocation of the lunate. There is also a tiny avulsion fracture on the ulnar aspect of the adjacent triquetrum.
The patient was referred to orthopedics for a perilunate dislocation of the left wrist. He underwent successful closed reduction and was placed in a short arm cast for four weeks.
A 15-year-old boy presents for evaluation of left wrist pain. He says that two days ago, while playing football, he fell onto his outstretched left hand, which twisted upon impact with the ground. Immediately after the fall, he experienced severe pain. Since then, the pain has been constant, although it lessens to a moderate dull ache at rest and sharpens with activity. He denies any numbness or tingling in the affected hand and wrist. There are no other areas of injury from the fall, nor is there significant medical history. Physical exam identifies moderate left wrist swelling with focal tenderness over the volar aspect of the distal radius, extending to the wrist. The patient has limited active and passive flexion and extension of the left hand and wrist, along with reduced grip strength due to pain. There is mild navicular tenderness. Radial pulse is 2+, the hand is warm to the touch, and the skin is intact. Sensation is intact in all of the digits, which also demonstrate brisk capillary refill. Radiographs of the left wrist are obtained. 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.
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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.
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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.
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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.
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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.
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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?
