CASE BASED REVIEW OF CRITICAL PLAIN

FILM IMAGING FINDINGS

Michael DiGianvittorio DO

February 6, 2015

MEAPA 25th Annual CME Conference

Objectives Case based

interactive review of 10 “don’t miss” plain film findings

Detect! Describe! Differential! Do what comes

next!

Case 1: 36yo female with atraumatic left hip pain

Returns 3 wks later with similar symptoms

Original Presentation3 wks later

Another 4 wks later…

Coronal CT Coronal STIR MRI

Flouroscopy Guided Hip Aspiration

Septic Arthritis Radiographs/CT

1st sign joint effusion○ Look for displaced fat

pads/stripes!!! Cartilage destruction joint

space loss Cortical bone indistinct Erosions

MRI Most sensitive

US Highly sensitive for joint

effusion Can be used to guide

aspiration

Case 2: 2 yo with tender abdomen

Intussusception Ileocolic most

common type Radiography

Meniscus of soft tissue in air filled colon

Typically RUQ Ultrasound

2.5-5.0cm mass with target appearance

Treatment?

Air Reduction Enema

Preparation: Surgery consult; IV access

Technique: Good rectal seal; 120mmHg max pressure; up to 3 attempts

Case 3: 18mo old with cough

Case 3: 18mo old with cough

Skeletal Survey

Skeletal Survey

Nonaccidental Trauma Radiography

Fractures of varied age Metaphyseal corner fractures Scapula fracture Sternal fracture Spinous process fracture

Bone Scan Takes 7-72hrs to become

positive Very sensitive

CT/MRI Used to assess for CNS

trauma○ Extraaxial hemorrhage○ Axonal injury○ Retinal hemorrhage

Case 4: 26yo with pharnygitis

What next?

Contrast Enhanced CT

Supraglottitis Aka “Adult Epiglottitis” Relatively uncommon

potentially life threatening infection and/or inflammation of supraglottis larynx

Sore throat & dysphagia Most resolve with IV abx

+/- steroids 15% require intubation or

trachestomy Airway compromise less

common than pediatric epiglottitis

Supraglottitis Often clinical diagnosis Plain Film

Lateral project key Thickened epiglottis and

aryepiglottic folds Decreased aeration of

valeculae and piriform sinuses

DDx: SCCa; laryngeal edema related to trauma or radiation

CT Used to evaluate for

complications (abscess) or to narrow differential

Case 5: 40yo with wrist pain following FOOSH

Case 5: 40yo with wrist pain following FOOSH

Scaphoid Fracture

Scaphoid Fracture

PA Oblique

Scaphoid Fracture Fall on outstretched

hand Pain at “anatomic

snuffbox” Mid 1/3 (“waist”)

70% Proximal 1/3

20% Distal 1/3

10%

Scaphoid Blood Supply

Proximal pole entirely dependent on intraosseous blood flow.High risk of non-union or AVN.

Scaphoid FracturePlain film

○ 1st line○ Can obtain “scaphoid

view” – ulnar deviation

Scaphoid Fracture CT

If plain film negative or equivocal

Assess for delayed union, nonunion, AVN

Pre-op planningThin section direct

sagittal along long axis of scahoid

Scaphoid Fracture MRI

Assess for radiographically occult fracture or for vascular compromise of proximal fragment

Marrow edema on fluid sensitive sequence if fracture acute

Nonenhancing if vascular compromise

AVN = hypointense

Scaphoid Fracture 90% eventually heal Complications

“Humpback deformity”○ Most common deformity

associated with malunion Delayed Union

○ Incomplete union after 4 mos

Non Union○ Failure to heal within 6

mos AVN

○ Occurs in 10-15%

h

Scaphoid Fracture Treatment

Casting○ Used in nondisplaced

mid or distal fractures○ 3-6 mos○ 90% heal

Surgical Intervention○ Unstable○ Displaced○ Symptomatic

malunion or nonunion○ Osteonecrosis

Case 6: Neck pain following trauma

Case 6: Neck pain following trauma Cervical Spine Plain

FilmAll 7 segments seen?

Case 6: Neck pain following trauma Cervical Spine Plain

FilmAll 7 segments seen?Alignment

Case 6: Neck pain following trauma Cervical Spine Plain

FilmAll 7 segments seen?AlignmentVertebral body height

Case 6: Neck pain following trauma Cervical Spine Plain

FilmAll 7 segments seen?AlignmentVertebral body heightFracture

Case 6: Neck pain following trauma Cervical Spine Plain

FilmAll 7 segments seen?AlignmentVertebral body heightFracture Prevertebral soft

tissues

Cervical Spine Injury

Cervical Spine Injury Evaluation of

prevertebral soft tissues is essential!

Look for the retropharyngeal fat stripe

Soft tissues may be only clue on plain film of underlying fracture or ligamentous injury

Case 7: 85yo with dyspnea. ? PNA

Reverse S-sign of Golden Coexistence of

superomedial displacement of minor fissure and hilar mass in setting of RUL atelectasis

EtiologyLung cancer (most

common)LymphadenopathyMediastinal massEndobronchial lesion

Reverse S-sign of Golden

Case 8: Neonate with increasing abdominal distention

Pneumatosis Intestinalis: NEC

Idiopathic enterocolitis in low birth weight premature neonatesUsually wks 1-3

Combination of infection and ischemia

Bubble-like or curvilinear lucencies

Pneumatosis Intestinalis: NEC

Gas can extend into extend into peritoneal space in the setting of perforated viscus or can extend into mesenteric vv portal veins

Thickened and dilated bowel loops

Distal ileum and right colon most common

Pneumatosis Intestinalis: NEC

Overal mortality 20-30% (sepsis from perforation)

TreatmentIV nutrition and abx

Bowel strictures possible in patients who survive

Free air = absolute indication for surgery

Case 9: 75yo with back pain following fall

No prior lumbar spine imaging available for comparison

Case 9: Compression Deformity

Compression Deformity Often impossible to

determine age via plain film unless prior imaging available for comparison

MRI Better define fracture

morphology and extent○ Stable vs unstanle

Acute vs chronic Healed vs nonhealed

Vertebroplasty

Vertebroplasty

Vertebroplasty

Final Case: 68yo with SOB and epigastric pain

Final Case: 68yo with SOB and epigastric pain

CT Chest

Esophageal Perforation: Boerhave’s Syndrome Distal esophageal

perforation following rapid increase in intraluminal pressure (violent emesis)

Tear usually left sided Extraluminal contrast Pneumomediastinum Pneumoperitoneum

Esophageal Perforation: Boerhave’s Syndrome Esophography with

water soluble oral contast

No barium!!! CT chest with oral

contrast given just before scan

Large perforations require immediate thoracotomy

Smaller perforations sometimes managed nonsurgically

Thank You!