Transcript Slide 1

35 things you really don’t want
to miss on an XRAY
Micelle Haydel, MD
LSUEM 2008
Learningradiology.com
Two patients with n/v
A
B
Large vs. Small Bowel

Large Bowel




Peripheral
Haustral markings don't
extend from wall to wall
Max diameter 6cm (9cm cecum)
Small Bowel

Central

Plica extend across lumen

Maximum diameter of 3cm
Patient A: SBO
Upright
Flat
Small bowel:<3cm
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)
Patient B: LBO
The Cecum is considered dilated if >9cm; other if >6cm.
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
Two more patients with n/v
A
B
A: Sigmoid Volvulus
B: Cecal Volvulus
A
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.
B
Sentinel
Cholecystitis
Appendicitis
Pancreatitis
Diverticulitis
Sentinel Loops
Supine
Abdominal Pain, NV
Mesenteric Ischemia/Infarction
• Thumbprinting
• Pneumatosis
intestinalis
Mortality 75%
Why this patient is short of breath?
Tension pneumothorax
Complete rightsided
pneumothorax
Lung is
compressed
against
mediastinum
Shift of
heart and
trachea to
left
A smaller Pneumothorax on CT
Ant
Post
Air in pleural
space rises to top
and displaces
normal lung
Another patient with SOB:
Skin Fold
Pneumothorax
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.
Bleb
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!
• Apical Cap
• Wide Lt Paratracheal
stripe that extends above
the knob
Traumatic aortic injury
Ruptured Diaphragm
Newborn with tachypnea
This person reports severe N/V and now has chest
pain, fever and SOB…
He sick!
Streaky, linear
densities due
to air in the
mediastinum
Pleural
effusion
Boerhaave’s
Air, air, everywhere
57 year-old female with shortness of breath
Meniscusshaped density
at bases from a
pleural effusion
Where are the
diaphragms?
Pleural Effusions
Meniscusshaped density
at right & left
base from a
pleural effusion
Pleural Effusions
Effect of Position - Layering
Supine
Erect
Pneumonias
Rt Lower lobe
Rt Upper lobe
Rt Mid lobe
Spine sign
Pneumonias
Left upper lobe
Lt Lower Lobe
Lt Lingula
Lt Lower Lobe
Cavitary Lesions
Thin wall: TB
Thick: CA or abscess
NV, Fever, RUQ pain
Gallbladder bad (aka,
emphysematous gallbladder)
Chief complaint: Abdominal Pain
Pneumoperitoneum
Air outlines
both sides of
the wall of the
stomach-a
sign of free
air in the
peritoneal
cavity
Pneumoperitoneum on CT
Free air
Free air
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
SOB
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
Sudden, severe Chest Pain, pale
diaphoretic…
•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
63 year-old man with chest pain
68 y/o w/Flank pain
Even if you’ve already called the surgeons and the OR,
you can start writing up your m&m…
Red arrows
point to active
extravasation of
contrast from
the aorta into
the
retroperitoneum
Aorta
Aorta
Thrombus
inside the lumen
of the aorta
Triple A: Aortic rupture
Post-intubation CXR
Tip of endotracheal tube is in right mainstem bronchus (red
arrow) leading to atelectasis of the right upper lobe and entire
left lung
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
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
Pacemakers
Where

Tip positioned at apex of right ventricle

Tip may have slight bend as it abuts wall of
right ventricle



Not a sharp bend
Some pacers may also have lead(s) in
right atrium and/or coronary sinus
Two-lead pacemaker (red circle) shows one lead in right atrium (green
arrow) and the second in the right ventricle (red arrow).
The End.
B
A
Two different people who fell & complain of neck pain
A
A
Spinolaminar
white line of C2
does not align
with other
vertebral bodies
Fracture
through
posterior
elements of C2
Fracture of C2 - “Hangman’s Fracture”
Forward
displacement
of the body of
C2 (red arrows)
The inferior
articular facet of
C5 (red arrow) has
slipped forward
and lies anterior
to the superior
articular facet of
C6 (green arrow)
B
C5
C6
— a condition
known as a
“locked facet”
Locked facets
Two patients-one with pain in the ankle, the other with pain
in the wrist
Fracture of
radial styloid
(yellow arrows)
extends into
wrist joint
Fractures of the
metaphysis (red
arrow) and
epiphysis (green
arrow) (SalterHarris IV) extend
into joint
Fractures extending into joints
27 year-old fell on elbow
Fracture of
radial head
Posterior “fatpad sign”
indicates fluid
in the joint
Fracture of the radial head with traumatic joint effusion
1
2
Two different patients with acute shoulder pain
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)
2
Anterior 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
Posterior Dislocation of the Shoulder
37 year-old hit in the head with a brick
Crescentic low
attenuation
lesion at
periphery of
brain containing
a fluid-fluid level
from blood
Traumatic intracranial hemorrhage
Subdural hematoma
Sudden Headache
Staggering gait & incontinence
Lateral
ventricles –
anterior and
posterior
horns
Large ventricles due to Cerebral Atrophy
MVA, H/A