PG Cases 321-360

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Describe your findings and what would you next?

Bilateral cystic lesions with septum in the both adnexa probably due to complex ovarian cysts.
Correlation with MRI recommended and tumour markers.

What examination is this and what are we looking for?

This is a CT cystogram. We are looking for extravasation of contrast from the bladder. No extravasation is seen here.
CT cystogram is indicated for:

• suspected bladder rupture
• fluoroscopic and CT cystography are considered equivalent for this indication
• postoperative bladder / suspected bladder leak

Describe this X-ray

An AP radiograph of the hips was obtained. The right femoral head is smaller than the left, and there is mild lateral subluxation of the right femoral head. The right acetabulum is shallow and dysplastic. The appearances are consistent with right-sided developmental dysplasia of the hip. The left hip is normal. Urgent orthopaedic consultation is recommended.

44 yr old male found collapsed post ?seizure and head injury with LOC. Describe your findings

There is an intraparenchymal haemorrhage in the left frontal lobe with mild surrounding oedema. Neurosurgical opinion is advised.

22 year old male fell off skateboard. What imaging has he had and describe the findings?

The patient has undergone a CT Tibia and Fibula. This reveals an extensive comminuted fracture of the proximal left tibia and tibial plateau. Innumerable fracture fragments. The lateral aspect of the tibial plateau is displaced laterally and no longer articulates with the distal femur.

33 year old man post fall from 10 feet, landed on left side with pain and bruising to the left chest . CT-AP shows?

The following is visible

• Laceration of the spleen with perisplenic haematoma compatible with a grade 3 injury and trace of free fluid around the liver.
• This patient was managed conservatively.
• Splenic injury is graded I-V, depending on extent and depth of splenic haematoma and/or laceration identified on CT scan. Low grade spleinic injuries I-III are suitable for non-operative management (BMJ 2014;348:g1864).

67 year old male with SOB and productive cough. What do you see?

Extensive right upper lobe and patchy right mid zone consolidation. Follow-up x-ray recommended in approximately 8 weeks time to ensure clearing of this consolidation. If the consolidation does not clear, CT thorax recommended to exclude underlying tumour.

77 y.o presented with vomiting and right sided abdominal pain. What can you see in this colonoscopy picture?

There is a mass at the hepatic flexure, approx 90% circumferential which is non-obstructing. There is a small sessile polyp adjacent to the tumor.
The patient underwent a biopsy of the mass, staging CT TAP and discussion at MDM

Can you see anything of note on this CXR?

There are very subtle well-defined small bullae in the periphery of the right upper lobe and the impression of subtle paraseptal emphysematous the right apex. The possibility of rupture of a small bullous should be considered. For further evaluation CT thorax can be considered.

PG_Case_349

31 year old female, unrestrained passenger in RTA. GCS: 3/15. What do you see on her CT Brain and what is your management plan?

There is an extensive acute left subdural haematoma in the left temporal, parietal and frontal regions. It is causing significant mass effect with midline shift to the right and the effacement of the left lateral ventricle. The patient requires urgent neurosurgical input

PG_Case_348

What do you see in this image and name a possible cause?

The left hemithorax is completely opacified with volume loss (which is due to previous pneumonectomy.) Sternotomy wires are seen. Calcification of the left upper zone. Mediastinal shift to the left. Background changes of COPD on the right. No acute lung lesion identified. The left fifth rib is missing which is due to previous resection

PG_Case_347

Describe this PFA

The bowel gas pattern is unremarkable. No evidence of obstruction. No subdiaphragmatic air to suggest perforation. No radiopaque renal or ureteric calculi identified. Metallic clips noted consistent with previous surgeries –gastric bypass and cholecystectomy. Phleboliths in pelvis.

PG_Case_346

What do you think the specimens in the jar are?

These are bladder stones. The patient reported that he passed these stones per urethra.

Because a bladder stone is in itself a sign of an underlying problem, both removal of the stone and treatment of the underlying abnormality are nearly always indicated. Management of the underlying cause of stone formation (eg, bladder outlet obstruction, infections, foreign body, or diet) is integral to prevention of recurrence.

PG_Case_345

What do you notice in this image?

There is oedema of subcutaneous tissues consistent with anasarca
Anasarca, or extreme generalized edema -characterized by widespread swelling of the skin due to effusion of fluid into the extracellular space.
It is usually caused by congestive heart failure, cirrhosis of the liver or renal failure.

PG_Case_344

Describe these X-rays and what is the patient at risk of?

There is an extensive comminuted fracture of the mid and distal right tibial diaphysis with slight angulation. There is a comminuted fracture of the distal fibular shaft with medial and anterior displacement of the distal fragments and overlap by approximately 3 cm. There may be an avulsed fracture of the dorsal aspect of the distal talus. There may be a fracture of the neck of the fibula proximally.

The patient is at risk of developing Compartment Syndrome. Signs of compartment syndrome include crescendo symptoms, pain with passive movement of involved muscles, paresthesias, and pallor, and a very late finding is pulselessness. Risk factors for compartment syndrome of the lower leg include tibial diaphysis fracture, soft-tissue injury, and crush injury

PG_Case_343

Describe what you see in these images.

Within the pelvis there is a mixed attenuation fluid distended “pseudo-viscus” which is anterior to the bladder. This is closely related to the posterior aspect of the rectus sheath and the bladder is decompressed taken to the back of this. This could be a large rectus sheath haematoma. The central attenuation is higher than muscle appears to be haemorrhagic. There is some inflammatory change around this. This may be reactive or infected.

PG_Case_342

Describe what you see.

In segment 5/4 B of the liver in the surgical bed is a subtle loculated air-fluid collection with peripheral enhancement suggestive of abscess formation.
This patient was 2/52 post liver resection and requires IV antibiotics and discussion regarding intervention: placement of drain/surgical wash-out

PG_Case_341

What is this and what does it test for?

The stool guaiac test or guaiac faecal occult blood test (gFOBT) is one of several methods that detects the presence of faecal occult blood

The test involves placing a faecal sample on guaiac paper. If the test is positive, the guaiac resin within the reagent paper is oxidized by the hydrogen peroxide of the developer solution and changes to blue. To make this happen, a haemoglobin molecule must support the chemical reaction as a catalysing agent.

PG_Case_340

Do you see anything abnormal on this image?

There is a large right inguinal lymph node. No retroperitoneal or iliac adenopathy.

Inguinal Lymph nodes
Divided into a deep and a superficial group
Superficial nodes -these are arranged in form of a letter T:
The vertical group along the great saphenous vein.
The horizontal group parallel to the inguinal ligaments.

Area of Drainage
Superficial tissues of the lower limb except the lateral foot, heel and back of the leg which drain into popliteal lymph nodes
Gluteal region.
Trunk below the umbilicus.
The perineum including the distal third of the anal canal, vagina and urethra
External genitalia except the testis and the glans penis/ clitoris
Fundus and the body of the uterus

Deep Nodes -these are arranged along the femoral vein and drain these areas:

  • Deep structures of the lower limb
  • Glans penis or clitoris
  • They are connected by lymph vessels to the superficial nodes and also to the external iliac nodes.

PG_Case_339

Describe this CT urogram image

The appearances on the left side would be consistent with a long-standing pelviureteric junction obstruction and a background of bladder outlet obstruction. The bladder is thick walled and appears to be high-pressure in appearances. There is perinephric free fluid which appears capsulated around the left kidney the margins are enhancing.
If the hydronephrosis does not resolve on urethral catheterisation, the patient may require a left sided nephrostomy

PG_Case_338

Do you know what procedure is occurring here?

Fluoroscopic guided nerve root block
• The patient was positioned prone on the fluoroscopy table.
• Aseptic technique.
• Suitable skin entry sites were marked using fluoroscopic guidance.
• The skin and subcutaneous tissues at the selected injection sites were anaesthetised using 10 cc 1% lidocaine.
• 22-gauge spinal needles were advanced towards the respective neural exit foramina.
• Confirmation of adequate needle tip positioning confirmed by injection of small volumes of contrast media.
• Medication (triamcinolone 40 mg; 0.5% bupivacaine 2cc) injected at each site following negative aspiration.
• Post procedure care instructions given to patient.

PG_Case_337

Describe these X-rays

Right ankle in cast. Mortise is normal. ORIF in the lateral malleolus of the right ankle. Normal alignment at the fracture site.

PG_Case_336

Patient presented with head injury, unequal pupils intubated due to low GCS. Describe your findings and management ?

There is an acute right subdural haematoma 12 mm in maximum depth with significant midline shift of approximately 4 mm and evidence of active bleeding. This associated with significant mass effect on the right lateral ventricle and subfalcine herniation. There is a smaller left anterior extradural collection and there is a left frontal haemorrhagic contusion. Bilateral scalp haematomas noted
The patient requires urgent neurosurgical input
Surgery for emergent decompression has been advocated if the acute subdural hematoma is associated with a midline shift greater than or equal to 5 mm. Surgery also has been recommended for acute subdural hematomas exceeding 1 cm in thickness. These indications have been incorporated into the Guidelines for the Surgical Management of Acute Subdural Hematomas proposed by a joint venture between the Brain Trauma Foundation and the Congress of Neurological Surgeons, released in 2006.
These guidelines also call for emergent decompression in a comatose patient with an acute subdural hematoma less than 1 cm in thickness causing a midline shift of less than 5 mm if any of the following criteria are met:

• The GCS score decreases by 2 or more points between the time of injury and hospital evaluation
• The patient presents with fixed and dilated pupils
• The intracranial pressure (ICP) exceeds 20 mm Hg

PG_Case_335

Describe this CT urogram image

The appearances on the left side would be consistent with a long-standing pelviureteric junction obstruction and a background of bladder outlet obstruction. The bladder is thick walled and appears to be high-pressure in appearances. There is perinephric free fluid which appears capsulated around the left kidney the margins are enhancing.
If the hydronephrosis does not resolve on urethral catheterisation, the patient may require a left sided nephrostomy

PG_Case_334

Describe your findings?

Shattered spleen in the upper pole with significant haemo peritoneum due to the splenic injury. Large perisplenic haematoma with active extravasation of the IV contrast.
The trend in management of splenic injury continues to favour non-operative or conservative management. This varies from institution to institution but usually includes patients with stable hemodynamic signs, stable hemoglobin levels over 12-48 hours, minimal transfusion requirements (2 U or less), CT scan injury scale grade of 1 or 2 without a blush, and patients younger than 55 years.

PG_Case_333

What is this and how does it form?

A bunion is a painful bony bump that develops on the inside of the foot at the big toe joint. Bunions are often referred to as hallux valgus.
A bunion forms when the bones that make up the MTP joint move out of alignment: the long metatarsal bone shifts toward the inside of the foot, and the phalanx bones of the big toe angle toward the second toe. The MTP joint gets larger and protrudes from the inside of the forefoot.

PG_Case_332

What do you see in this image and name a possible cause?

The left hemithorax is completely opacified with volume loss (which is due to previous pneumonectomy.) Sternotomy wires are seen. Calcification of the left upper zone.
Mediastinal shift to the left. Background changes of COPD on the right. No acute lung lesion identified. The left fifth rib is missing which is due to previous resection.

PG_Case_331

What do you see and what are the common causes?

This patient has colitis. Common causes include

  • Inflammatory bowel disease (IBD) (Crohn’s disease or ulcerative colitis)
  • Chemical colitis.
  • Ischemic colitis.
  • Infectious colitis
  • Medication induced colitis

PG_Case_330

What is the arrow pointing to?

Nephrostomy is a term used to describe a passageway maintained by a tube, stent, or catheter that perforates the skin, passes through the body wall and renal parenchyma, and terminates in the renal pelvis or a calyx.
The nephrostomy has multiple functions but is used most frequently to provide urinary drainage when the ureter is obstructed and retrograde access is inadvisable or impossible.

PG_Case_329

What has happened here? How would you manage it?

Patellar dislocation is usually caused by either a direct trauma to the knee or from a sudden twist or pivoting of the leg. A dislocation occurs when the patella shifts out of its normal position in the patellofemoral groove. The first step will be returning it to its normal position (reduction) and can sometimes happen spontaneously.

Nonoperative treatments -NSAIDS, activity modification, and physiotherapy –mainstay of treatment for first time patellar dislocation (without any loose bodies or intraarticular damage)

PG_Case_328

Describe what you see here

Fluoroscopic guidance provided for internal fixation of angulated oblique fracture of the neck of the proximal phalanx of the right little finger

PG_Case_327

Describe your findings and what would you next?

Bilateral cystic lesions with septum in the both adnexa probably due to complex ovarian cysts.
Correlation with MRI recommended and tumour markers.

PG_Case_326

Describe your findings

Bennett’s type Fracture at the base of the first metacarpal right hand. Bennett fracture is a fracture of the base of the first metacarpal bone which extends into the carpometacarpal (CMC) joint. This intra-articular fracture is the most common type of fracture of the thumb, and is nearly always accompanied by some degree of subluxation or frank dislocation of the carpometacarpal joint.

PG_Case_325

Compare the two x-rays.

The bones are diffusely osteopenic. There is a fracture in distal left clavicle with interval deterioration in alignment.
The patient requires orthopaedic opinion.

PG_Case_324

Patient presented with x2/7 RIF pain, nausea and anorexia. What can you see on these images?

There are a number of an appendicoliths in the appendix. The appendix is thickened measuring 1.5 cm in maximum transverse dimension. There is inflammatory change in the adjacent mesenteric fat. Findings compatible with acute appendicitis. The patient requires an appendicectomy

PG_Case_323

What findings can you see on this image from an MRI left femur?

There is a mass in the subcutaneous fat overlying the left greater trochanter measuring 7.9 x 2.7 x 7.0. This is intimately related to the tensor fascia lata.The adjacent tissues are normal in signal intensity and morphology. The underlying bone is normal. The appearance is most compatible with a Morel Lavallee lesion

Morel-Lavallée lesions typically occur when the skin and subcutaneous fatty tissue traumatically and abruptly separate from the underlying fascia.

  • The initial injury represents a shearing of subcutaneous tissues away from underlying fascia. The initial potential space created superficial to the fascia is filled by various types of fluid, ranging from serous fluid to frank blood.
  • The collection may then spontaneously resolve or become encapsulated and persistent.
  • Once these lesions become established and encapsulated then conservative management is rarely successful (e.g. compression bandages).
  • Surgical drainage may be sufficient, although in some instances the capsule needs to be resected to prevent re-accumulation.

PG_Case_322

Patient presented with left ankle dislocation which was reduced and then imaged. Describe your findings

Trimalleolar fractures. Ankle mortise is satisfactorily aligned.
Trimalleolar fractures means that all three malleoli of the ankle are broken, -medial, lateral and posterior. These are unstable injuries and they can be associated with a dislocation.

PG_Case_321

Do you know what prodecure is occurring here?

Fluoroscopic guided nerve root block
The patient was positioned prone on the fluoroscopy table.
Aseptic technique.
Suitable skin entry sites were marked using fluoroscopic guidance.
The skin and subcutaneous tissues at the selected injection sites were anaesthetised using 10 cc 1% lidocaine.
22-gauge spinal needles were advanced towards the respective neural exit foramina.
Confirmation of adequate needle tip positioning confirmed by injection of small volumes of contrast media.
Medication (triamcinolone 40 mg; 0.5% bupivacaine 2cc) injected at each site following negative aspiration.
Post procedure care instructions given to patient.