Tag Archives: what the heck?

What The Heck? Some Hints!

Yesterday, I presented the case of a young man with abdominal pain a few weeks after a splenectomy for trauma. One slice of the CT scan was presented, which showed pneumatosis in the wall of the cecum.

There have been some great comments from readers with some interesting reasoning, especially from StillChucklesandNP. Here’s another piece of the puzzle, yet another slice from the CT scan:

  • What’s this?
  • Any other important information?
  • What’s the diagnosis and why?
  • How do you treat it?

Looking forward to more tweets and comments! Answers tomorrow.

What The Heck?

Here’s an interesting one for you to solve!

A 20ish year old male was involved in a motor vehicle crash, sustaining a Grade IV spleen injury. He fails nonoperative management early in his hospital course, undergoing a splenectomy 6 hours later.

He has an uneventful recovery and is ready for discharge after 5 days. His platelet count has plateaued at 600K. He presents to your ED 2 weeks later complaining of abdominal pain. On exam, he is diffusely but mildly tender. His subjective complaints appear to be a bit out of proportion to his exam.

Here is one slice from his CT scan. I’ve put a nice fat arrow on it to help out. But it won’t.

image

  • What does the scan show?
  • Why is it there?
  • What other key piece of information do you want to know?
  • Any other studies?
  • Then what?

Some hints tomorrow! Tweet your answers or leave comments below! Let’s see if anyone can figure this one out!

What The Heck? Bicycle Trauma Answer

So a young male jammed a handlebar into his abdomen, and a CT image demonstrating his problem was shown. But what did it actually show?

By now, you probably realize that clinical information is key. On exam, he had an obvious bulge in his left lower quadrant, more obvious with straining. Looking at the CT (now with a nice arrow), there is a problem over the left side of the abdomen. 

image

This child has so little fat, that it’s difficult to see the problem. If you track the thin layer of fat across the abdomen to the right side of the image, you’ll see that it disappears over the bowel gas. This represents a complete tear through all fascial layers, not just a Spigelian hernia as some readers guessed.

Management consisted of primary repair of the defect. An uneventful recovery can be expected. Unless more bicycle tricks are anticipated.

Reference: Traumatic handlebar hernia: a rare abdominal wall hernia. J Ped Surg 39(10):e20-e22, 2004.

What The Heck? Bicycle Trauma Part 2

Yesterday’s puzzle involved a young male who drove a handlebar into his abdomen. Little additional information was given, other than one slice of his abdominal CT scan. So what’s the problem?

The textbooks always associate handlebars with pancreatic and duodenal injuries, and these should always be looked for. However, the scan slice in this case was taken lower, within the pelvis. Too low to show you either of those organs.

As I’ve said before, be systematic when reading xray images. We automatically focus on the viscera and bones. Look at those areas, make sure you can identify each structure that you see, and look for any anomalies. 

But don’t forget the soft tissue! In this case, the child doesn’t have much. Take a closer look at the same slice and see if you can figure it out by tomorrow.