@ER_Rad_Hanna

@ER_Rad_Hanna

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 15

Hx: Fall. Back Pain

Professionally appropriate gif responses only please. Extra points for not using the obvious answer. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #MSKRad #NeuroRad

Silly Twitter, lets keep it together now 🤣

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

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

#WetreadCoW Case 15 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.#FOAMed #FOAMrad #Neurorad #MSKRad #radres

Read 6 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 15

Hx: Vaginal bleeding

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

Professionally appropriate gif responses only please. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #bodyrad

@ER_Rad_Hanna @GayatriJoshiMD @RadioGyan #WetreadCoW Case 15 (cont)

+Urine pregnancy test

Diagnosis(es)? Gifs only please! 😀 FOAMrad #FOAMed #radres #errad #bodyrad

#WetreadCoW Answer: Cervical Ectopic Pregnancy

Imaging is easy!

-⭐️NO IUP(endometrium opposed, no fluid or sac)
-gestation sac w/ fetal pole in cervix

Options:
1) cervical ectopic
2) spont abortion

Here: Closed os, no endometrial fluid➡️ectopic
#FOAMrad #bodyrad #errad #obgyn

Read 9 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 14

Hx: Abominal Pain

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

Professionally appropriate gif responses only please. No spoilers! #FOAMrad #FOAMed #radres

A case for everyone 😀 #errad #bodyrad #chestrad #NeuroRad

#WetreadCoW Answer: Tuberous Sclerosis

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

*remember ⬆️size of AMLs = ⬆️ risk of hemorrhage

#FOAMed #FOAMrad #bodyrad #radres

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 rb.gy/rlkgei

Read 5 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 13

Hx: 50 yo male with cough

Please answer with professionally appropriate gif responses only. No spoilers. wetread.org #FOAMrad #FOAMed #radres #errad #chestrad

@RyanBPetersonMD

@RyanBPetersonMD @ER_Rad_Hanna @StefanTigges @RadioGyan @jannimd @thoracicrad #WetreadCoW Case 13

Got the CT for you. Does it help?

@WetreadCoW Case 13 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

#FOAMed #FOAMrad #chestrad #radres #thoracicrad

Read 4 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 12

Hx: heel pain

Please answer with professionally appropriate gif responses only. No spoilers. wetread.org #FOAMrad #FOAMed #radres #errad #mskrad #orthorad

#WetreadCoW Case 12 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) #FOAMrad #FOAMed #radres #mskrad #orthorad

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 ❌=symptoms (like plantar spur ❌=plantar fasciitis sx)

Read 3 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 11

Hx: abdominal distention

Please answer with professionally appropriate gif responses only. No spoilers. #FOAMrad #FOAMed #radres #errad #bodyrad

#WetreadCoW Case 11 Answer: Pseudomyxoma Peritonei

-accumulation of mucinous ascites from mucin producing tumor. This case is the classic mucinous appendiceal tumor s/p multiple debulking surgeries! #FOAMed #FOAMrad #Radres #bodyrad

👍 on the gifs everyone!

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

Read 5 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 10

Hx: trauma survey exam. Fall, pain

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

Please answer with professionally appropriate gif responses only. No spoilers. #FOAMrad #FOAMed #radres #errad #orthorad #MSKRad

#WetreadCoW Case 10 Answer: Ankylosing Spondylitis

-fused SI jts
-fused pubic symphysis
- interspinous ligament ossification = "dagger spine"
-fused Lspine?

⭐️Need to look for spine fx!

Too easy? or maybe everyone is distracted by #ASER2020
#FOAMed #radres #mskrad #orthorad

Ank Spon:

-seroneg spondyloarthropathy (neg Rheum factor) ➡️ 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

Read 5 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 9

Hx: MVA, chest pain

Please answer with professionally appropriate gif responses only. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #chestrad

#WetreadCoW Case 9 Answer: Diverticulum of Kommerell

Focal outpouching of the distal aortic arch + h/o trauma ➡️ think traumatic PSA⭐️, but lets look a bit closer here

No perioaortic stranding
No wall thickening
location = medial (retroesophageal 🤔)
#FOAMrad #radres #chestrad

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 subcl in setting of R aortic arch OR aberrant R subcl in normal L aortic arch (here) #FOAMed #FOAMrad #radres

Read 5 tweets

Ryan Christie

@RyanChristieMD

@RyanBPetersonMD

#WetreadCoW Case 8

Hx: 30yo female w abdominal pain

Please answer with professionally appropriate gif responses only. No spoilers. wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad @RyanBPetersonMD @ER_Rad_Hanna @RadioGyan

#WetreadCoW Case 8 Answer: Hepatic Adenoma w hemorrhage

Multiple hyperenhancing hepatic masses in a young female. Largest in L lobe w hyperdensity (blood)➡️irreg contour w mild extracapsular hemorrhage #FOAMrad #radres #bodyrad #ERrad

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 even➡️exsanguination!

#FOAMed #FOAMrad

Read 5 tweets

Ryan Christie

@RyanChristieMD

@thoracicrad

#WetreadCow Case 7

Hx: chest pain

Please answer with professionally appropriate gif responses only. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #chestrad @thoracicrad @chestcases @TanMohammedMD

#WetreadCow Answer: Sprengel's Deformity

-M/C congenital abnl of the shoulder

-Failure of ⬇️ scapula (starts mid-cervical)

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

-shoulder asymmetry w ⬇️ ABduction

#FOAMed #radres #chestrad #chestcases #orthorad

Sprengel's Imaging:

- ⬆️ (blue arrows) and ↪️(red arrow) scapula so inf tip points to spine (? smaller)

- Uni- or Bi- lateral

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

-👀 for rib/spine abnl (green arrows) (K-F)

Read 4 tweets

Ryan Christie

@RyanChristieMD

@thoracicrad

#WetreadCow Case 6

Hx: survey CXR after MVA

Please answer with professionally appropriate gif responses only. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #chestrad

Can I play? 😀 @thoracicrad @chestcases @TanMohammedMD

@chestcases

#WetreadCoW Case 6 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 @chestcases #FOAMed #errad #chestrad

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

Read 5 tweets

Ryan Christie

@RyanChristieMD

Wetread Case 5

Hx: abdominal pain

Please answer with professionally appropriate gif responses only. No spoilers. wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad #bodyrad

@RyanBPetersonMD

@RyanBPetersonMD @ER_Rad_Hanna @RadioGyan Wetread Case 5

More images helpful?

@bwells80 @GayatriJoshiMD @HKhasawneh @tdelae

#WetreadCow Case 5 Answer: Ischemic Bowel

Fluid filled ?dilated bowel loops 👍 All the same? ❌

R abd loops (red) = thickened w/o enhancement vs those in the L abd (blue) which = early obstruction or ileus.

Surgery=necrotic bowel! #FOAMed #FOAMrad #radres #ERrad #bodyrad

Read 5 tweets

Ryan Christie

@RyanChristieMD

#WetreadCow Case 4

Hx: MVA, neck pain

Please answer with professionally appropriate gif responses only. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #Neurorad #MSKRad

#WetreadCow Case 4

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 ❌
-Post 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 👀 for the fracture!

Read 5 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 3

Hx: Chest pain

Diagnosis? (it's August, we're starting easy! I'm giving you PA AND Lat! 😀)

Professionally appropriate gif responses only please. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #chestrad #bodyrad

#WetreadCOW Case 3 Answer: Bochdalek Hernia

Large round opacity right lung base.

On frontal does NOT obscure anterior diaphragm or R heart border - ie posterior/RLL

On lateral DOES "obscure" entire posterior R diaphragm

#Chestrad #ERRad #radres #FOAMrad

Bochdalek Hernia

-congenital defect in posterior diaphragm attachment
- Can be either side (classic =L side in symptomatic infants➡️lung hypoplasia, but R m/c in adults?)
- typically only fat but ~25% can contain abd organs

Hint: 🅱️ochdalek = 🅱️ack

#radres #chestrad #FOAMed

Read 3 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Case 2

Hx: Fall, pain

Anyone know my name?

Please answer with professionally appropriate gif responses only. No spoilers. wetread.org #FOAMrad #FOAMed #radres #errad #mskrad #orthorad

#WetreadCow Answer: Barton Fracture

Distal radial fx but only involves dorsal aspect of the distal radius (volar aspect is intact). Radial styloid ok on oblique?🤔

Barton fx=shear fx of dorsal distal radius

Shear off volar aspect=reverse Barton fx
#mskrad #orthorad #FOAMrad

This fx is not too displaced, but as the fx fragment displaces more, the carpal bones often dislocate with it. If we cone in tightly we can see the scaphoid/lunate are starting to migrate with the dorsal fragment

W/o proper trt, this can cause long term wrist pain/instability

Read 4 tweets

Ryan Christie

@RyanChristieMD

#WetreadCoW Season 9 Case 1 - back to the basics

Hx: Line placement 😮 OR is calling now for a STAT report. Look OK?

Please answer with professionally appropriate gif responses only. No spoilers! wetread.org #FOAMrad #FOAMed #radres #errad #chestrad

#WetreadCoW S9C1 Answer

1)Malpositioned left subclavian catheter (extends into R IJ)
2)Malpositioned right jugular Swan-Ganz catheter (extends into hepatic vein)

Did you see both? You have to check every one! 🤬

#FOAMrad #FOAMed #radres #chestrad #radtwitter #MedTwitter

@radiologistpage

Let go through them. Correct ones first.

ETT - tip below the thoracic inlet and >2cm above carina ✅

GI tube - tip/side port below GE junction (hard to see but I think so)✅

Mediastinal drain ✅

Right chest tube x 2✅ (No pneumothorax)

I'm not @radiologistpage but I try 🤣

Read 6 tweets

Ryan Christie

@RyanChristieMD

Wetread Summer Series Case 8

Hx: shoulder pain

Please answer with professionally appropriate gif responses only. No spoilers. wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad #orthorad #MSKrad

#WetreadCow SS Case 8

Answer: Septic joint + osteomyelitis (humerus + glenoid)

+RTC tear or two on MRI 😮

-Cortical destruction w/ ⬆️⬆️osteopenia
-large jt effusion
- ⬆️ soft tissue swelling

These go bad VERY fast! Aspiration is key!
#FOAMrad #radres #errad #orthorad #MSKrad

This was literally a Friday 5PM walking out the door case. To this day it reminds me:

1) Provided Hx can be useless (your 👀 >> indication)
2) Cortex, Cortex, Cortex - examine all the cortical margins
3) Soft tissues are your friend!
4) Beware first and last case of the day 😉

Read 3 tweets

Ryan Christie

@RyanChristieMD

Wetread Summer Series Case 7

Hx: scrotal pain (we got a bit different hx from the pt...)

Please answer with PROFESSIONALLY APPROPRIATE gif responses only. No spoilers. wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad #bodyrad

#Wetread SS Case 7 Answer: Penile Fracture

Hx was actually classic "Heard pop w/ pain during intercourse"

US shows 1 corpus spongiosum + 2 corpus cavernosa. Examine for rupture of the tunica albuginea which surrounds the CC and CS ->deflation. Hematoma (red) extends proximally.

-Hx is typical
-Imaging classic once you get there.

-ER often just orders a scrotal US (need penile US).
-Uncommon so US techs may/may not know how to scan

Get trans/long images looking for CC/CS ruptured hyperechoic albuginea and/or hematoma

Urtheral injuries rare but occur

Read 3 tweets

Ryan Christie

@RyanChristieMD

Wetread Summer Series Case 6

Hx: pelvic pain (pregnancy test pending 🙄)

Please answer with professionally appropriate gif responses only. No spoilers! wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad #bodyrad #obgyn

Here are some coned down views that may be helpful.

Wetread SS Case 6 Answer: Ruptured Heterotopic Pregnancy (IUP + ruptured ectopic pregnancy)

Too easy?🤔 No one likes OB?☹️🤣

+IUP generally excludes ectopic pregnancy. Here's the rare exception proving the rule. Labeled gif below for #radres. #WetreadCow #FOAMed #errad #bodyrad

Read 4 tweets

Ryan Christie

@RyanChristieMD

Wetread Summer Series Case 5

Hx: dizziness

Anything of interest?

Please answer with professionally appropriate gif responses only. No spoilers! wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad #NeuroRad

Wetread SS Answer: Persistent Primitive Trigeminal Artery (PPTA)

We don't need a CTA to see the now ca++ primitive connection between the right cavernous ICA and basilar artery

Tau sign is the classic description on the sagittal CTA/MRA #WetreadCOW #FOAMed #radres #Neurorad

Persistent Carotid-Vertebrobasilar Anastamoses:

-Embryologic connections
-Normally regress
-Named by cranial nerve it follows

Caudal->Cranial: "HOT"

Hypoglossal - cervical ICA (C1-C3)
Otic - petrous ICA - rare/controversial
Trigeminal - cavernous ICA->basilar a (most common)

Read 3 tweets

Ryan Christie

@RyanChristieMD

Wetread SS Case 4

Hx: hip dislocation

Initial and post reduction films. Thoughts? 🤔 There may be a CT coming 😉

Professionally appropriate gif responses only. No spoilers! wetread.org #WetreadCow #FOAMrad #FOAMed #radres #errad #MSKRad

@AdamSingerMD

@AdamSingerMD @StefanTigges @ER_Rad_Hanna @RyanBPetersonMD Pt still had pain and limited ROM so CT was ordered. Anything wrong here?

#WetreadCow Answer: dislocated arthroplasty liner

Femoral head component does not sit centrally in the acetabular component because the radiolucent liner has dislocated into a communicating fluid collection (ie circular lucency lateral to troch!)#FOAMed #radres #MSKrad #orthorad

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