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

Two patients with n/v B A

Large vs. Small Bowel Large Bowel Small 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 B

A: Sigmoid Volvulus B: Cecal Volvulus 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.

Sentinel LOOPS Cholecystitis Pancreatitis Appendicitis Diverticulitis

Sentinel Loops Supine

Abdominal Pain, NV

Mesenteric Ischemia/Infarction Thumbprinting Pneumatosis intestinalis Mortality 75%

Why this patient is short of breath? Why this patient is short of breath?

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

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

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… 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 57 year-old female with shortness of breath

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

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

Effect of Position - Layering 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 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 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…

Triple A: Aortic rupture 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.

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

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

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” B C5 C6 Locked facets

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

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

27 year-old fell on elbow

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

Two different patients with acute shoulder pain 1 2 Two different patients with acute shoulder pain

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

Posterior Dislocation of the Shoulder 1 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 Humeral head (red arrow) lies posterior to the glenoid fossa of the humerus (yellow arrow) Posterior Dislocation of the Shoulder

37 year-old hit in the head with a brick

Traumatic intracranial hemorrhage Subdural hematoma 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

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

MVA, H/A