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35 things you really don’t want to miss on an XRAY Micelle Haydel, MD LSUEM 2008 Learningradiology.com.

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Presentation on theme: "35 things you really don’t want to miss on an XRAY Micelle Haydel, MD LSUEM 2008 Learningradiology.com."— Presentation transcript:

1 35 things you really don’t want to miss on an XRAY Micelle Haydel, MD LSUEM 2008 Learningradiology.com

2 Two patients with n/v A B

3 Large vs. Small Bowel l Large Bowel n Peripheral n Haustral markings don't extend from wall to wall n Max diameter 6cm (9cm cecum) l Small Bowel n Central n Plica extend across lumen n Maximum diameter of 3cm

4 Patient A: SBO Flat Upright Small bowel:<3cm

5 Radiology Report: Plain abdominal radiograph. Multiple dilated loops of small bowel within the central abdomen. Gas is not seen in the large bowel. The three most common causes of small bowel obstruction are: Surgical adhesions Herniae Intraluminal mass eg, small bowel lymphoma or gallstone (in gallstone ileus)

6 Patient B: LBO The Cecum is considered dilated if >9cm; other if >6cm.

7 Radiology Report: Plain abdominal radiograph. Multiple dilated loops of large bowel across the abdomen. Gas is not seen in the large bowel. The three most common causes of large bowel obstruction are: Ca Diverticular disease Volvulus

8 Two more patients with n/v A B

9 A: Sigmoid Volvulus B: Cecal Volvulus A B A volvulus always extends away from the area of bowel twist. Sigmoid volvulus can only move upwards and usually goes to the right upper quadrant. Cecal volvulus can go almost anywhere.

10 Pancreatitis Diverticulitis Cholecystitis Appendicitis Sentinel

11 Sentinel Loops Supine

12 Abdominal Pain, NV

13 Mesenteric Ischemia/Infarction Thumbprinting Pneumatosis intestinalis Mortality 75%

14 Why this patient is short of breath?

15 Tension pneumothorax Complete right- sided pneumothorax Lung is compressed against mediastinum Shift of heart and trachea to left

16 A smaller Pneumothorax on CT Post Ant Air in pleural space rises to top and displaces normal lung

17 Another patient with SOB: A skin fold consists of a density (light) and then a lucency (dark), A pneumothorax has a thin white line with similar densities on both sides of it. Skin Fold Pneumothorax

18 Bleb

19 URD, front end collision, high speed MVA Now, same patient, upright cxr… You are looking for a marker of aortic injury: mediastinal hematoma Mediastinal widening >8cm Left paratracheal stripe Displacement of intimal calcifications Apical pleural cap Left pleural effusion Displacement of endotracheal tube or nasogastric tube About 10% will have a normal CXR!

20 Apical Cap Wide Lt Paratracheal stripe that extends above the knob

21 Traumatic aortic injury

22 Ruptured Diaphragm

23 Newborn with tachypnea

24 This person reports severe N/V and now has chest pain, fever and SOB…

25 Boerhaave’s Pleural effusion Streaky, linear densities due to air in the mediastinum He sick!

26 Air, air, everywhere

27 57 year-old female with shortness of breath

28 Pleural Effusions Meniscus- shaped density at bases from a pleural effusion Where are the diaphragms?

29 Pleural Effusions Meniscus- shaped density at right & left base from a pleural effusion

30 Effect of Position - Layering SupineErect

31 Pneumonias Spine sign Rt Mid lobe Rt Upper lobe Rt Lower lobe

32 Pneumonias Left upper lobe Lt Lower LobeLt Lingula Lt Lower Lobe

33 Cavitary Lesions Thin wall: TB Thick: CA or abscess

34 NV, Fever, RUQ pain

35 Gallbladder bad (aka, emphysematous gallbladder)

36 Chief complaint: Abdominal Pain

37 Pneumoperitoneum Air outlines both sides of the wall of the stomach-a sign of free air in the peritoneal cavity

38 Pneumoperitoneum on CT CT scans on 2 different people show a small and large amount of free air in the peritoneal cavity which rises to the highest point (anterior abdomen with the person lying on their back) and is not contained within bowel Free air

39 SOB

40 Size (not number) of vessels at the apex exceeds size of vessels at the base in this upright person. This is “cephalization.” Normally the vessels at the base exceed the size of the vessels at the apex

41 Sudden, severe Chest Pain, pale diaphoretic…

42 Widened mediastinum Neuro findings Chest pain: sharp, sudden, severe, radiating to back Sudden Pain, at its max immediately should make you think of an aortic dissection

43 63 year-old man with chest pain

44 68 y/o w/Flank pain

45 Even if you’ve already called the surgeons and the OR, you can start writing up your m&m…

46 Triple A: Aortic rupture Thrombus inside the lumen of the aorta Red arrows point to active extravasation of contrast from the aorta into the retroperitoneum Aorta

47 Post-intubation CXR

48 Tip of endotracheal tube is in right mainstem bronchus (red arrow) leading to atelectasis of the right upper lobe and entire left lung

49 Endotracheal Tubes Where Tip should be at least 5cm above carina Between clavicles and carina Carina usually at level of T4 Balloon should never distend tracheal walls; if >2.8 cm, suspect laceration

50 Central Venous Catheters Where Subclavian joins brachiocephalic vein behind medial end of clavicle Catheter should reach this point before descending Catheter should descend lateral to spine and tip should be in the SVC

51

52 l Tip positioned at apex of right ventricle n Tip may have slight bend as it abuts wall of right ventricle l Not a sharp bend l Some pacers may also have lead(s) in right atrium and/or coronary sinus Pacemakers Where

53 Two-lead pacemaker (red circle) shows one lead in right atrium (green arrow) and the second in the right ventricle (red arrow).

54 The End.

55 Two different people who fell & complain of neck pain A B

56 Fracture through posterior elements of C2 Forward displacement of the body of C2 (red arrows) Spinolaminar white line of C2 does not align with other vertebral bodies Fracture of C2 - “Hangman’s Fracture” A A

57 Locked facets The inferior articular facet of C5 (red arrow) has slipped forward and lies anterior to the superior articular facet of C6 (green arrow) — a condition known as a “locked facet” C5 C6 B

58 Two patients-one with pain in the ankle, the other with pain in the wrist

59 Fractures of the metaphysis (red arrow) and epiphysis (green arrow) (Salter- Harris IV) extend into joint Fracture of radial styloid (yellow arrows) extends into wrist joint Fractures extending into joints

60 27 year-old fell on elbow

61 Posterior “fat- pad sign” indicates fluid in the joint Fracture of radial head Fracture of the radial head with traumatic joint effusion

62 Two different patients with acute shoulder pain 1 2

63 Anterior Dislocation of the Shoulder 2 Humeral head (red arrow) lies inferior to the coracoid process of the scapula (green arrow) Humeral head (red arrow) lies inferior to the glenoid fossa of the scapula (yellow arrow) Humeral head (red arrow) lies inferior to the coracoid process of the scapula (green arrow) and anterior to the glenoid (yellow oval)

64 Posterior Dislocation of the Shoulder 1 Humeral head (red arrow) lies posterior to the glenoid fossa of the humerus (yellow arrow) Humeral head (red arrow) lies beneath the acromion process of the scapula (green arrow) and posterior to glenoid (yellow oval) Humeral head (red arrow) assumes the shape of a “lightbulb” because it is fixed in internal rotation

65 37 year-old hit in the head with a brick

66 Traumatic intracranial hemorrhage Subdural hematoma Crescentic low attenuation lesion at periphery of brain containing a fluid-fluid level from blood

67 Sudden Headache

68 Staggering gait & incontinence

69 Large ventricles due to Cerebral Atrophy Lateral ventricles – anterior and posterior horns

70 MVA, H/A


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