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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?
“Something Abnormal” on a Chest X-ray
ANSWER
The radiograph demonstrates a fairly large (4 x 6 cm) right paratracheal mass of unclear etiology. This type of finding warrants further evaluation with contrasted CT.
Fortunately for this patient, a subsequent study demonstrated a slightly enlarged thyroid gland. This correlated with the radiographic
finding.
ANSWER
The radiograph demonstrates a fairly large (4 x 6 cm) right paratracheal mass of unclear etiology. This type of finding warrants further evaluation with contrasted CT.
Fortunately for this patient, a subsequent study demonstrated a slightly enlarged thyroid gland. This correlated with the radiographic
finding.
ANSWER
The radiograph demonstrates a fairly large (4 x 6 cm) right paratracheal mass of unclear etiology. This type of finding warrants further evaluation with contrasted CT.
Fortunately for this patient, a subsequent study demonstrated a slightly enlarged thyroid gland. This correlated with the radiographic
finding.
You are doing preoperative orders on a patient scheduled for surgery tomorrow morning. The patient is a 75-year-old woman who was admitted with an acute left subdural hematoma after sustaining a ground-level fall. Her medical history is significant for hypertension and diabetes. Social history is unremarkable. She is neurologically intact except for occasional confusion and aphasia. She moves all her extremities well. As you review her lab results, one of the nurses mentions that the radiology department called about “something abnormal” on the patient’s chest radiograph. You pull up the patient’s portable chest radiograph on the computer to review. What is your impression?
Man Falls on Buttocks
ANSWER
There are degenerative changes present. Bilateral hip prostheses are noted. Within the coccyx, there is bone remodeling and angulation that are likely chronic and related to remote trauma or injury (arrow). Below this, some cortical lucency (circled) is noted, most likely consistent with an acute fracture. The patient was prescribed a nonsteroidal medication and a mild narcotic pain medication.
ANSWER
There are degenerative changes present. Bilateral hip prostheses are noted. Within the coccyx, there is bone remodeling and angulation that are likely chronic and related to remote trauma or injury (arrow). Below this, some cortical lucency (circled) is noted, most likely consistent with an acute fracture. The patient was prescribed a nonsteroidal medication and a mild narcotic pain medication.
ANSWER
There are degenerative changes present. Bilateral hip prostheses are noted. Within the coccyx, there is bone remodeling and angulation that are likely chronic and related to remote trauma or injury (arrow). Below this, some cortical lucency (circled) is noted, most likely consistent with an acute fracture. The patient was prescribed a nonsteroidal medication and a mild narcotic pain medication.
A 75-year-old man presents to the urgent care center for evaluation of pain in his buttocks after a fall. He states he was walking when his “legs gave out” and he hit the ground. He landed squarely on his buttocks, causing immediate pain. He was eventually able to get up with some assistance. He denies any current weakness or any bowel or bladder complaints. His medical/surgical history is significant for coronary artery disease, hypertension, and bilateral hip replacements. Physical exam reveals an elderly male who is uncomfortable but in no obvious distress. His vital signs are stable. He has moderate point tenderness over his sacrum but is able to move all his extremities well, with normal strength. Radiograph of his sacrum/coccyx is shown. What is your impression?
Thrown From Motorcycle
ANSWER
Several findings are evident from this radiograph. First, the quality is slightly diminished due to the patient’s size and artifact from the backboard. The patient’s mediastinum is somewhat widened, which is concerning for possible occult chest/vascular injury. There is some haziness within the left apical region suggestive of a hemothorax; no definite pneumothorax is seen. The left clavicle is fractured and displaced, and the left scapula is fractured as well.
ANSWER
Several findings are evident from this radiograph. First, the quality is slightly diminished due to the patient’s size and artifact from the backboard. The patient’s mediastinum is somewhat widened, which is concerning for possible occult chest/vascular injury. There is some haziness within the left apical region suggestive of a hemothorax; no definite pneumothorax is seen. The left clavicle is fractured and displaced, and the left scapula is fractured as well.
ANSWER
Several findings are evident from this radiograph. First, the quality is slightly diminished due to the patient’s size and artifact from the backboard. The patient’s mediastinum is somewhat widened, which is concerning for possible occult chest/vascular injury. There is some haziness within the left apical region suggestive of a hemothorax; no definite pneumothorax is seen. The left clavicle is fractured and displaced, and the left scapula is fractured as well.
A 57-year-old man is brought to your facility as a trauma code. He was riding a motorcycle on the highway, traveling approximately 45 to 50 mph, when the car in front of him abruptly stopped. He hit the car and was thrown from his bike. He believes he briefly lost consciousness but recalls emergency personnel tending to him. On arrival, he is awake and alert, complaining of pain in his neck, left arm, and left lower leg. Medical history is significant for borderline hypertension and a previous accident that resulted in an emergency laparotomy. Primary survey reveals stable vital signs: blood pressure of 157/100 mm Hg; heart rate, 110 beats/min; respiratory rate, 20 breaths/min; and O2 saturation, 98% with supplemental oxygen. Pupils are equal and reactive; there are slightly decreased breath sounds on the left side. Abdominal exam appears benign. There is decreased mobility and pain in the patient’s left upper and left lower extremities, although no obvious deformity is noted. Preliminary chest radiograph is obtained before the patient is sent for CT. What is your impression?
Clipped by an Oncoming Car
ANSWER
The image shows a comminuted and depressed fracture of the lateral tibial plateau. It is depressed approximately 6 to 7 mm. The patient was admitted, and orthopedic consultation was obtained. The patient subsequently underwent an open reduction and internal fixation of the fracture.
ANSWER
The image shows a comminuted and depressed fracture of the lateral tibial plateau. It is depressed approximately 6 to 7 mm. The patient was admitted, and orthopedic consultation was obtained. The patient subsequently underwent an open reduction and internal fixation of the fracture.
ANSWER
The image shows a comminuted and depressed fracture of the lateral tibial plateau. It is depressed approximately 6 to 7 mm. The patient was admitted, and orthopedic consultation was obtained. The patient subsequently underwent an open reduction and internal fixation of the fracture.
A 23-year-old man is brought in after being hit by a car. He was in the process of getting into his car when another vehicle coming from the opposite direction swerved into his lane. He tried to jump onto his hood to avoid the other car but was struck by the side mirror and landed on the ground. He is primarily complaining of left knee and lower leg pain. He denies any medical history. Primary survey appears to be stable except for scalp and facial lacerations. The patient is awake, alert, and oriented, and his vital signs are stable. His left lower extremity is in a splint immobilizer, placed by emergency medical personnel. There is a moderate amount of soft tissue swelling around the knee, which is exquisitely tender to palpation. The patient has limited flexion and extension of the knee due to pain. He is able to wiggle his toes, and distally in the leg and foot there appears to be no neurovascular compromise. Radiographs of the tibia are obtained. What is your impression?
Inmate Falls From Top Bunk
ANSWER
The radiograph demonstrates no acute osseous injury, such as fracture or dislocation. Of interest and note is increased sclerosis within both femoral heads, more so on the left versus the right side. Given the patient’s young age, such findings could be related to early avascular necrosis. His clinical symptoms certainly correlate. MRI or bone scan, as well as orthopedic evaluation, is warranted in such a case.
Fortunately, subsequent MRI of both hips did not show any avascular necrosis but rather osteoarthritic changes. The MRI of his spinal column was negative as well.
ANSWER
The radiograph demonstrates no acute osseous injury, such as fracture or dislocation. Of interest and note is increased sclerosis within both femoral heads, more so on the left versus the right side. Given the patient’s young age, such findings could be related to early avascular necrosis. His clinical symptoms certainly correlate. MRI or bone scan, as well as orthopedic evaluation, is warranted in such a case.
Fortunately, subsequent MRI of both hips did not show any avascular necrosis but rather osteoarthritic changes. The MRI of his spinal column was negative as well.
ANSWER
The radiograph demonstrates no acute osseous injury, such as fracture or dislocation. Of interest and note is increased sclerosis within both femoral heads, more so on the left versus the right side. Given the patient’s young age, such findings could be related to early avascular necrosis. His clinical symptoms certainly correlate. MRI or bone scan, as well as orthopedic evaluation, is warranted in such a case.
Fortunately, subsequent MRI of both hips did not show any avascular necrosis but rather osteoarthritic changes. The MRI of his spinal column was negative as well.
A 30-year-old man is transferred to your facility for evaluation of reported paraplegia after a fall. The patient is an inmate at a local prison. He states he was sleeping on the top bunk when he rolled over and fell off the bed, landing flat on his back on the concrete floor. He immediately started having severe back and hip pain and noticed that he could not move his legs. His primary complaint is severe bilateral hip pain. He was initially evaluated at an outside hospital, where CT of his head, cervical spine, and lumbar spine was negative for any acute pathology. He was sent to your facility for an MRI to rule out contusion or acute herniated disc. The patient denies any significant medical history, including back trauma. Currently, he reports no bowel/bladder issues or saddle anesthesia. On initial exam, he is awake, alert, and oriented, with normal vital signs. Musculoskeletal exam demonstrates a moderate amount of paraspinous tenderness and bilateral hip/pelvis tenderness. There is no instability detected, nor any leg shortening or rotation. He does have bilateral weakness in both lower extremities on the magnitude of 3-/5, although his exam seems limited due to the severity of his hip pain. Sensation is completely intact in both lower extremities. While the patient is awaiting his MRI, you order a portable pelvis radiograph, since none was performed at the outside facility. What is your impression?
Elderly Woman Takes a Fall
ANSWER
The radiograph shows the lungs overall to be clear. There are some slight increased markings, perhaps suggestive of mild congestion, but no infiltrate or consolidation.
Of note is a small nodule within the middle portion of the left upper lobe that requires monitoring and further workup. Also, although it is incompletely imaged, there appears to be a fracture of the right humeral neck.
Additional imaging confirmed the fracture. Orthopedic consultation was obtained.
ANSWER
The radiograph shows the lungs overall to be clear. There are some slight increased markings, perhaps suggestive of mild congestion, but no infiltrate or consolidation.
Of note is a small nodule within the middle portion of the left upper lobe that requires monitoring and further workup. Also, although it is incompletely imaged, there appears to be a fracture of the right humeral neck.
Additional imaging confirmed the fracture. Orthopedic consultation was obtained.
ANSWER
The radiograph shows the lungs overall to be clear. There are some slight increased markings, perhaps suggestive of mild congestion, but no infiltrate or consolidation.
Of note is a small nodule within the middle portion of the left upper lobe that requires monitoring and further workup. Also, although it is incompletely imaged, there appears to be a fracture of the right humeral neck.
Additional imaging confirmed the fracture. Orthopedic consultation was obtained.
A 90-year-old woman is complaining of pain on the left side of her face, her chest wall, and right shoulder. Her family reports that she has fallen multiple times recently. On one occasion, there was brief loss of consciousness. History is significant for hypertension and osteoarthritis. Initial examination indicates she is awake, alert, oriented, and in no obvious distress. Vital signs are stable, and breath sounds are clear. There is tenderness on the left side of her face and decreased range of motion in her right shoulder, as well as localized tenderness. The hospitalist ordered a chest radiograph when the patient was admitted. What is your impression?
Hand Pain Following an Altercation
ANSWER
The radiograph shows moderate soft-tissue swelling with dislocation of the proximal interphalangeal joint. No definite fracture is seen. In addition, there are some metallic-appearing foreign bodies.
The patient was treated with closed reduction and splinting. He also received a referral to outpatient orthopedics for follow-up.
ANSWER
The radiograph shows moderate soft-tissue swelling with dislocation of the proximal interphalangeal joint. No definite fracture is seen. In addition, there are some metallic-appearing foreign bodies.
The patient was treated with closed reduction and splinting. He also received a referral to outpatient orthopedics for follow-up.
ANSWER
The radiograph shows moderate soft-tissue swelling with dislocation of the proximal interphalangeal joint. No definite fracture is seen. In addition, there are some metallic-appearing foreign bodies.
The patient was treated with closed reduction and splinting. He also received a referral to outpatient orthopedics for follow-up.
A 60-year-old man presents with a complaint of pain in his right fifth finger following an altercation. He is not sure exactly how the injury occurred, but he does recall that at one point his hand was twisted awkwardly. He denies any significant medical history. His vital signs are normal. Primary survey appears normal as well. On examination, you notice moderate swelling around the fifth finger of his right hand, which does appear to be slightly deformed. There are no obvious wounds or lacerations. He has moderate tenderness at the base of his finger. Range of motion is limited due to the swelling. Good capillary refill time is noted. The triage nurse already sent the patient for a radiograph of his finger (shown). What is your impression?
