Not your ordinary arm fracture…

This patient was shoveling, had sudden onset of forarm pain…

Radius fx 2 radius fx

This is a pathologic fracture from a forearm malignancy.  The patient’s primary malignancy was rectal adenocarcinoma.  This is a rare place for a metastasis.

The mechanism for this patient did not support a broken bone.  However one should keep in mind pathologic fractures when deciding whether to obtain plain films.  Plain films in the ED are quick, inexpensive, and don’t come with significant radiation risks.  I usually argue these points with my residents when discussion about plain film utilization in musculoskeletal pain.

Author:  Russell Jones, MD


Filed under: Arm XR, Orthopedics, Trauma, XR Tagged: Arm

Liver mass…differential diagnosis

This patient presented with right upper quadrant pain.  I asked last week what your differential diagnosis would be:

Liver Mass 1

Liver mass 2

The CT above shows a multiloculated, rim-enhancing mass in the liver parenchyma.  This is consistent with an abscess.  The differential diagnosis starts by breaking down the categories into bacterial, fungal, and amebic causes. 

Bacterial:  Abscesses can form from ascending cholangitis, especially in setting of biliary malignancies.   Klebsiella pneumoniae has been reported to cause hepatic abscesses, especially in E. Asia (1).  Patients with recent instrumentation (hepatocellular carcinoma embolization, etc) are at risk for MRSA, streptococcus species.  Tuberculosis has been known to cause hepatic abscesses as well.

Fungal:  Disseminated candidiasis in the immunocompromised host can lead to liver and splenic abscesses

Amebic:   Liver abscess is the most common manifestation of extraintestinal entamoeba histolytica (2).  In endemic areas or travelers to endemic areas are at risk for this occurrance. 

Author:  Russell Jones, MD

References

1.  Davis J, McDonald M.  Pyogenic Liver Abscesses.  www.uptodate.com

2.  Leder K, Weller P.  Extraintestinal Entamoeba Histolytica Amebiasis.  www.uptodate.com

 


Filed under: Abdomen/Pelvis, Abdomen/Pelvis, CT, Non-Trauma Tagged: Abscess

WWWTP #17 Answer…

This is a pediatric radiograph of a patient with wrist pain after a fall:

SHII fx distal radius II SHII fx distal radius

 

There is a subtle linear lucency on the distal radius, best seen on the lateral view.

This is a Salter-Harris Type II Distal Radius fracture.  For a refresher on Salter-Harris classification see:

Salter-Harris

Author:  Russell Jones

References

1.  Salter-Harris Fracture.  http://en.wikipedia.org/wiki/Salter–Harris_fracture


Filed under: Eponyms, Orthopedics, Trauma, Wrist XR, WWWTP, XR Tagged: Salter Harris, Wrist

Aortic dissection…

This patient presented with chest pain radiating to the back:

AD CXR 1

 

The patient’s initial chest X-ray shows a widened mediastinum and an indistinct aortopulmonary window.  CT showed:

AD CT 1 AD CT 2 AD CT 3

This patient has an aortic dissection.  There are two different classification systems for aortic dissection:  Stanford and DeBakey (1).

Stanford Criteria:

  • Type A:  The dissection flap involves the ascending aorta
  • Type B:  The dissection commences distal to the left sub-clavian artery

DeBakey Criteria

  • Type I: The dissection flap involves the ascending aorta and descending aorta
  • Type II:  The dissection flap involves the ascending aorta only
  • Type III:  The dissection flap involves the descending aorta only

This is a Stanford Type A and a Debakey Type I because it involves the ascending aortic arch all the way to the iliac bifurcation.

What is important to remember (besides the number for a cardiothoracic surgeon)?  If the flap involves the ascending aorta these are usually managed operatively. Descending dissections are many times managed medically (1).

Besides rupture, the main problem with aortic dissection is perfusion to various organs.  Virtually every solid organ can be affected depending on the spacial characteristics of the dissection flap.  In this case the last image clearly shows that the right kidney is not perfused, indicating that the dissection flap has occluded the right renal artery.  The kidneys and bowel are the most common organs to develop ischemia.

Author:  Russell Jones, MD

Image Contributor:  Jay Williams, MD

References

  1. Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier, 2011.

Filed under: Chest, Chest XR, CT, Non-Trauma, Vascular, XR Tagged: Aortic Dissection