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.
- 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!
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.
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.
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.
You figure it out. As usual, you get limited information up front.
An early teenage male was doing some crazy stuff with his bicycle. Unfortunately, he slipped, striking his abdomen on the handlebar.
Using this image alone, figure out the problem. Comment below or tweet your guesses! More tomorrow and Thursday.
This patient was involved in a motor vehicle crash with significant chest trauma. They’ve been intubated and are oxygenating and ventilating well. What to do next?
First, the endotracheal tube was a bit deep, which can create its own problems. It was pulled back a few centimeters. Since the patient was hemodynamically stable, a CT angio of the chest would be very helpful to try to figure out the pathology. Here’s a representative slice from the scan.
There are a few striking findings here:
- Extensive subcutaneous emphysema
- Large pneummediastinum around the heart
- Significant injury to the left lung (note the pneumatocele, an air filled collection)
- Atelectasis of the left lung despite repositioning of the ET tube
The combination of of the above is highly suggestive of a large airway injury. Since the entire lung was affected, it is most likely a mainstem bronchus injury. Usually, these are accompanied by a large air leak from the chest tube, but not in this case.
This prompted the bronchoscopy shown two days ago. The image is oriented such that the left mainstem bronchus was on the right side of the video. A bronchial tear is visible on the lateral aspect, just before the takeoff of the upper lobe bronchus. You can get the impression of a beating heart beating somewhere nearby. And when the camera pops through the laceration, you can actually see the thoracic aortic coursing away toward the diaphragm!