History: abdominal pain and distention

Answer: Cecal volvulus

= torsion of the cecum around it's mesentery

• ~10% of intestinal volvuli 30-60 yo
• often prior abd surgery or pelvic mass
• present as prox colon obstruction (pain,n,v, distention)

Cecal Volvulus
2 types:

• Axial - twists about axial plane (either way) but remains in RLQ
• Loop type - twists and inverts moving to LUQ

Bascule is a variant where the cecum doesn't twist, just folds up anteriorly (NO torsion!)

From UpToDate (a=axial, b=loop, c=bascule):

Cecal Volulus Imaging:
X-ray: marked dilated colon loop extending from RLQ to LUQ (remember cecum dilation is >9cm)

• -haustra usually maintained
• -can have SINGLE air-fluid level

CT: exactly what you expect - dilated cecum with "bird beak" at site of orsion/obstruction

Cecal Volvulus:

Look for wall thickening, pneumotosis, free air, arterial cut-offs or venous dilation/obstruction - all concerning signs for ischemia

Often when mesentery twists it pulls in other loops (see sigmoid below)

Treatment:
Surgery vs colonscopic decompression

Cecal vs Sigmoid volvulus

Not always as simple as it sounds.

1. Loop for straight (cecal) vs upside down U-shaped (sigmoid) dilated colon loop

2. Is the descending colon decompressed (cecal) or dilated (sigmoid)?

History: Chest Pain

So hopefully everyone saw this pleural based opacity in the RUL.  But does anyone see the other finding?

Turns out pt had some pain radiating to their neck so they got this C-spine X-ray.  Perhaps one of the rare times a non-trauma C-spine X-ray is helpful?

Answer: Pancoast tumor (aka superior sulcus tumor)

RUL Pleural density is a rib met from the destructive tumor in the R pulmonary apex. Where is Right C7 TP?

These can be VERY difficult to see so you have to examine the apices closely on all CXR!

Pancoast tumor:

-varying tumor types (NSCLC m/c)

-classic hx is Pancoast Syndome (chest pain, C8-T2 radiculopathy, Horner's syndrome) but only ~25% have all 3

-often involves brachial plexus and subcl vessels to trt is radx/chemo +/- resection

-poor 5yr survival

Pancoast Tumor (Imaging)

CXR: soft tissue mass pulm apex. Look for bone destruction!

CT: improved resolution over CXR

MRI: Look for nerve/vessel involvement (if >C8 nerve involvement may be inoperable)

PET/CT: nodal, distant mets

My rec is to always examine and re-examine the lung apices, with a magnifying glass!

Look for:

• Soft tissue density (scarring v mass)
• bone destruction
• nodules
• PTX!!
  ***HINT: you often get a better look at the apices on the coned down C-spine CT than on the full FOV Chest CT

History: Wrist Pain

Answer: Trans-scaphoid Perilunate dislocation

-lunate still "normal" position while other carpal bones dislocate dorsally ++ assoc scaphoid fx! (count the proximal row!)

Perilunate Dislocation:

Mechanism: high-energy trauma (MVA) or FOOSH (fall on outstretched hand)

Injury: torn radioscaphoid, scapholunate & lunotriquetral ligaments.

Look for the scaphoid fx!

Imaging:

-Frontal: lunate appears triangular ("pie sign") & overlaps capitate

-Lateral: lunate "normal"w other carpal bones dislocated (typically dorsal). Somtimes slight palmar tilt from the capitate trying to get back to normal -capitate not sitting in "cup" of lunate

Perilunate Dislocation is often confused with LUNATE dislocation.

Although there are similarities, just remember what is actually dislocating.

Is the lunate dislocated?

Yes=LUNATE dislocation

NO,but other bones dislocated? = PERI-lunate dislocation

Hx: Fall. Back Pain

ER went ahead and ordered the CT CAP.  Does this help?

Turns out the patients pain was more T/L junction and L-spine.

Answer: Butterfly vertebra

Vertebral anomaly from lack of fusion of the 2 sides of a vertebral segment (?due to persistent notochordal tissue) -> bowtie appearance on frontal or 2 wedges connected at their tips.

Butterfly Vertebra are generally incidental. Key is to NOT dx as a compression fx.

+corticated borders!

+sup and inf endplates involved

+lat borders normal (post wall ~nl)

+V-shaped endplates -> bowtie appearance vs U shaped endplates which -> "H-shape" in Sickle-cell vs uniform ht loss

Butterfly Vert:

CT is tricky. Axials show butterfly or Pac-man appearance. Since the anterior body never formed. This yields kyphosis/gibbus deformity (resembling ant compression fx)so you often get some of the adjacent vertebra on your slice(below).

Look for symmetry & cortication!

Sagitals show BIG-small-BIG w varying degrees of anterior height - again look for symmetry!

If only 1 side present = a hemivertebra -> lat scoliosis

Typically incidental findings in young adults, but can be assoc w: Alagille syndrome and VACTERL

History: Vaginal Bleeding

What is the first question to ask? What are the possible diagnoses? (more images to come of course!)

First question of a pelvic ultrasound is ALWAYS: Is the patient pregnant?

(+)Urine pregnancy test

Answer: Cervical Ectopic Pregnancy

Imaging is easy! -

NO IUP(endometrium opposed, no fluid or sac)

Here there is a gestation sac w/ fetal pole in cervix

Options:

1) cervical ectopic

2) spont abortion

Here: Closed os, no endometrial fluid = ectopic!

Ectopic W/U:

***ALWAYS check pregnancy status in ANY female that COULD be pregnant.***

Ectopic is often dx of exclusion!

+Pregnancy test

#1 IUP? Yes=Done. No=too early or spontaneous AB or ectopic

#2 bHCG? descrim level=3500*. >3500 =not too early

#3 bHCG trend? Decreasing =AB, Stable or Increasing = ectopic

*Some may ask bHCG of 3500?

2018 ACOG Practice bulletin rec raising descriminatory level to 3500 for a single quant bHCG when utilized with a transVAGINAL US in order to minimize the risk of overtreating o/w nl early IUPs with mtx.

ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy : Obstetrics & Gynecology

management using methotrexate. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely…

LWW

Ectopic Pregnancy

-can be ANYWHERE but ~95% tubal (m/c ampulla)

-3% cornual/interstitial - present late with increased risk of bleed

-~1% ovarian

-<1% cervical

-<1% "scar" (site of prior C-section)

-1% abdominal

Risks: IVF, altered anatomy (h/o PID, IUD, tubal ligation, etc), maternal age

Ectopic Pregnancy Imaging

-empty uterus

-live extra-uterine gestation(rare)

-often see NOTHING

-complex mass adj to ovary(can resemble corpus luteum but CL is IN the ovary) -tubal ring about sac

-Doppler ring of fire -seen with CL as well!

-endometrial fluid ie pseudogestational sac

Cervical Ectopic Treatment:

Cervical Ectopic Trt -IM mtx limited effect - NO DNC due to increased risk of severe hemorrhage

-Intrasac mtx or KCL (if +hr) -IR uterine artery embo -hysterectomy

History: Abdominal pain

Can you identify the source of acute pain and the underlying etiology?

Perhaps some additional images from the same patient?

Answer: Tuberous Sclerosis

More specifically - multiple large bilateral renal angiomyolipomas through the kidneys (green) with acute R perinephric hemorrhage (red arrows)

*remember increasing size of AMLs = increasing risk of hemorrhage!

Tuberous Sclerosis (aka Bourneville Dz)

-neurocutaneous disorder (phakomatosis)

-numerous benign tumors of ectodermal orgin (skin, eyes, CNS)

-usually sporatic

-Classic: child with Vogt's triad (seizures, intellectual disability, adenoma sebaceum https://rb.gy/rlkgei

Tuberous Sclerosis (Chest):

-lymphangiomyomatosis (LAM)

-varying size, thin walled, spherical intrapulmonary cysts with uniform distribution

-multifocal micronodular pneumocyst hyperplasia (MMPH)

-numerous small pulmonary nodules

- Cardiac rhabdomyomas

Tuberous Sclerosis (Neuro)

• subependymal hamartomas (below)
• small Ca++ subependymal nodules
• subependymal giant cell astrocytomas (SGCA)
• Cortical/Subcortical tubers - Triangle shaped subcortical lesions with apex pointing to ventricles (majority in frontal lobes)

Hx: 50 yo male with cough

Answer: Mounier-Kuhn syndrome (aka tracheobronchomegaly)

-cystic dilation of trachea&bronchi

-absence/atrophy of elastin fibers&smooth muscle

-?congenital (not agreed upon)

-assoc w Ehlers-Danlos

Mounier-Kuhn Syndrome:

-consider when trachea >3cm (above aortic arch)

-bronchi >2cm (R) or >1.5cm (L)

-can have tracheal diverticula

-dynamic imaging shows change in airway diameter ( increased w inspiration due to weakness)

-yields chronic productive cough/infection and COPD symptoms

History: Heel Pain

Answer: Haglund's Syndrome

Haglund's deformity = post-sup calcaneal spur (red)="pump bump"

Haglund's syndrome = deformity +Kager's fat pad edema (blue)+thick Achilles @ insertion & retroAchilles bursitis (green)

Haglund's deformity/syndrome is assoc w use of rigid heel shoes, ex high heels (aka "pumps") -> irritation @ Achilles insertion & retroAchilles bursitis -> deformity+ edema+pain

US & MR show same thing!

Deformity(spur) alone does NOT necessarily =symptoms (similar to how plantar spur does not =plantar fasciitis symptoms)

Hx: abdominal distention

Answer: Pseudomyxoma Peritonei

-accumulation of mucinous ascites from mucin producing tumor.

This case is the classic mucinous appendiceal tumor s/p multiple debulking surgeries!

Pseudomyxoma Peritonei

Source: mucinous tumor of appendix (#1), colon, stomach, pancreas, urachus, ovary Rupture -> mucin & neoplastic cells into the peritoneum -> diffuse peritoneal spread of malignancy and increasing abdominal distention

Pseudomyxoma Peritonei (Imaging)

US - echogenic peritoneal masses

CT - low/simple fluid locules w mass effect +/- ring calcs

->scalloping of organ surfaces and centrally displaced small bowel

MR - low T1, high T2 (follows water) +/- enhance

Pseudomyxoma Peritonei Complications:

• fibrosis + adhesions -> recurrent bowel obstructions (can be fatal)

Treatment: +surgical debulking +intraperitoneal chemotherapy

Hx: trauma survey exam. Fall, pain

Dx? Anything else you may want to consider given the history?

Answer: Ankylosing Spondylitis

We have:

-fused SI joints

-fused pubic symphysis

- interspinous ligament ossification = "dagger spine"

-fused Lspine?

** Look for spine fx!

Ankylosing Spondylitis:

-seronegative spondyloarthropathy (neg Rheum factor) that yields fusion of the spine, SI jts, pubic symphsysis, and sometimes other jts

-assoc w HLA B27 gene
-M>F
-usually presents 3rd-4th decade
-trt: NSAIDS, motion/exercise, TNF-alpha blockers

Ankylosing Spondylitis Imaging

-sacroiliitis is bilateral & symmentric

-Romanus lesion - small vert corner erosion w sclerosis (shiny corner sign) -squaring of vert -"bamboo spine"

-parallel paravert syndesmophytes -"dagger spine" - interspinous lig ossif and so much more!

Ank Spon Complications:

Fractures! - although fused, bones are brittle and don't respond well to extreme motion/trauma. This yields "chalk stick" fx (snaps straight through). Can be subtle so look closely on CT.

Pseudoarthroses are common after fractures (example below).

Hx: MVA, chest pain

Answer: Diverticulum of Kommerell

If you see a focal outpouching of the distal aortic arch + h/o trauma = THINK traumatic pseudoaneurysm! But lets look a bit closer here.

-No perioaortic stranding

-No wall thickening

-location = medial (retroesophageal)

Kommerrell Diverticulum

-focal outpouching of the distal aortic arch at the origin of an aberrant subclavian artery (here artery is very small)

-can be aberrant L subclavian in setting of R aortic arch OR aberrant R subclavian in normal L aortic arch (here)

Coronal imaging is the key! Here you can see the diminutive aberrant R subclavian artery extending up to the right neck.

While acute aortic injury should be ALWAYS considered, with NO perioaortic stranding, NO evidence of aortic wall injury, & o/w NO thoracic trauma, this is c/w Kommerrell Diverticulum

Kommerrell Diverticulum

-developmental variant -often asymptomatic (can yield esoph/trach obstruction if large)

Imaging:

- dilated prox aberrant subclavian artery w or w/o entire artery

If big can yield indentation on esophagram

Treatment? - if big (>30mm) consider TEVAR/arch replace

Hx: 30yo female w abdominal pain

Answer: Hepatic Adenoma with hemorrhage

Multiple hyperenhancing hepatic masses in a young female. Largest in left lobe within internal hyperdensity (blood) and capsular irregularity consistent with extracapsular hemorrhage (hepatic rupture).

Hepatic Adenomas:

-Benign

-m/c hepatic tumor in young females classically on OCPs

-stimulated by estrogen (OCPs, obesity, anabolic steroid use)

-typically asymptomatic

-prone to hemorrhage which can even yield exsanguination!

Hepatic Adenomas Imaging:

Classic:

-solitary  (>10 = adenomatosis)

-large (5-15cm) at dx

-subcapsular, R hepatic lobe

-well defined -Ca++ uncommon (old bleed)

-US: varies

-CT: isodense to liver, early enhancement but iso-enhancing by portal venous phase. Hyperdense in a fatty liver or when containing hemorrhage

MR: T1 variable, T2 mild increased, +fat ->phase drop out

-contrast: early arterial enhancement then iso on delay (like CT)

-hemorrhage can distort this

Nucs: photopenic defect on Tc-99 sulfur colloid ( increased number & function of Kupffer cells)

Hx: Chest Pain

Answer: Sprengel's Deformity

-M/C congenital abnl of the shoulder

-Failure of Downward migration of scapula (starts mid-cervical)

-often part of Klippel-Feil Deformity (cervical vertebral fusion)

-shoulder asymmetry w decreased ABduction

Sprengel's Imaging:

• Upwardwards(blue arrows) and counter-clockwise rotation (red arrow) of the scapula so inf tip points to spine (sometimes smaller)

• Uni- or Bi- lateral

-Look for bony omovertebral bone (bony or fibrous scapulo-vertebral connection - usually C4-C7) - up to 50%

-Look for rib/spine abnl (green arrows) (Klippel -Feil)

Sprengel's Clinical

-Graded upon degree of elevation

-cosmetic and/or decreased shoulder mobility yields shoulder muscular hypoplasia/atrophy

-trt: physical therapy versus surgery

Hx: survey CXR after MVA

Answer: Continuous Diaphragm sign of Pneumomediastinum

The heart rests on the medial diaphragms, so normally they are silhouetted out. When we see them (blue arrows) it means there is air between the heart and diaphragm

This can be seen with pneumomediastinum or pneumopericardium.

There is a more subtle lucency about the high left heart border (yellow arrow) which is also consistent with pneumomediastinum.

These findings can be difficult to see on CXRs, esp when not involving the neck/axilla.

Multitude of causes but besides penetrating trauma, my experience has been tracheobronchial barotrauma is very common.

Boerhaave’s always seems to come up so inquire for correct hx (wretching/vomiting ?pill stuck?) and for  pleural fluid. Esophagram still gold standard to r/o

FYI: There does seem to be an association of this with inhaled illicit drug use (marijuana, cocaine). Typically in young males, ?barotrauma from breathe hold and deep coughing (I hear ) Condition is generally benign but often gets big w/u to exclude more concerning etiologies.

Hx: MVA, neck pain

Answer: Unilateral Facet Dislocation

Normal L & R superior articular facets overlap/aligned to the C6-C7 where 1 is shifted anterior(red dash)

-Ant & post vertebral lines (green) ?ok

-Spinolaminar line (orange)=broken

-Poseriort spinous line (purple) = gap

Perched facet = subluxed joint with tip of inferior facet resting on tip of super facet of lower body

Dislocated/jumped/locked facet = complete dislocation with inferior tip ANTERIOR to superior facet of lower body (thus “locked”)

Get the CT and ALWAYS look for the fracture!

Unilateral jumped facets can be tough on X-ray as the vert body doesn’t have to displace much (vert lines ok).

ALWAYS look at spinolaminar & posterior spinous lines!

Facets = “shingles on a roof"

Any abrupt change/rotation should be concerning!

For completeness, here is a bilateral facet dislocation.

ALL spinal lines disrupted. No rotation. Both inferior facets jumped and locked anterior to the superior facets of the lower body.

- MRI=diffuse ligamentous injury

- neurologically devastating