Charles F. Mueller

Asymptomatic esophageal perforation by a coin in a child

Ingestion of coins by children is a common event that rarely causes serious complications. We present a case of asymptomatic esophageal perforation by a penny in a child who presented with wheezing six months after the ingestion. When esophagography and triple endoscopy failed to show the perforation, thoracotomy resulted in successful removal of the foreign body, which was encased in granulation tissue between the trachea and esophagus. Complications of foreign body ingestion are discussed.

Traumatic injury of the diaphragm: Report of seven cases and extensive literature review

Seven proven cases of traumatic rupture of the diaphragm (TRD) following blunt trauma and an extensive 32-article review of 1345 cases of penetrating and blunt trauma are presented. The distribution of TRD was relatively consistent through the decades, with 458 cases of penetrating trauma (34%) and 887 cases of blunt trauma (66%); less than 1% of the cases were iatrogenic. There were 853 left-sided cases (67.2%), 359 right-sided cases (28.3%), and 48 bilateral and 10 central tendon cases (4.5%). In penetrating TRDs, 188 were left-sided (50%), 158 right-sided (42%), and 30 bilateral (8%). In the blunt TRDs, 606 were left-sided (73.1%), 195 right-sided (23.5%), and 18 bilateral and 10 central tendon (3.4%). Over 94% of 926 cases had another organ injured along with the diaphragm. There was an overall mortality of 21.6%; however, no fatalities were directly related to the TRD. Eighty-seven percent of TRDs were diagnosed within 24 hours, 81% within 12 hours, and 72% in less than 6 hours. The location of the laceration along the surface of the diaphragm was imperfectly described in the literature, offering no statistical information.The role of radiographic studies [plain films, barium studies, ultrasound, nuclear medicine, computed tomography (CT), and magnetic resonance imaging (MRI)] vs. surgical outcome in making the diagnosis of TRD is examined. Emphasis was placed on analyzing TRD in blunt trauma since it poses a more challenging clinical and radiographic dilemma in making a preoperative diagnosis. Plain radiographs were suggestive in 77% and diagnostic in 50% of TRD cases, while 47% were diagnosed at surgery and 3% by other radiologic studies. Barium studies are especially useful following a misdiagnosed TRD where the patient presents with a clinical history suspicious for strangulated abdominal viscera that occurred after herniation into the thorax.Radionuclide scanning may demonstrate liver within the thorax that herniated following a right-sided TRD. The role of CT is uncertain since we found only 32 cases (3.6%) in which CT was utilized, and only six of these (18.2%) were diagnostic for TRD. Early studies using MRI show high accuracy in dignosing TRD; it is especially valuable in uncertain cases. At present, nasogastric tube placement and serial chest radiographs are the recommended initial management for evaluating patients with potential TRD.

The significance of prevertebral soft tissue swelling in extension teardrop fracture of the cervical spine

The purpose of this study was to assess the relationship of prevertebral soft tissue (PVST) swelling and cervical spinal cord injury in extension teardrop fracture (ETF). Cervical spine radiographs and the clinical courses of 36 adult patients who sustained extension teardrop fracture(s) were reviewed retrospectively. Radiographic and neurologic findings were correlated. Thirty-two of 36 patients (89%) showed no evidence of cervical spinal cord injury throughout their clinical course, whereas 4 of 36 patients (11%) had a cervical myelopathy. In 30 patients with ETF and in whom the PVST shadow could be assessed, 7 (23%) had minimal or no PVST swelling, 18 (60%) had focal swelling, and 5 (17%) had diffuse/marked PVST swelling. Of the patients with ETF and no, minimal, or focal PVST swelling, none had cervical myelopathy. Four of 5 patients (80%) with ETF and diffuse/marked PVST and/or prior endotracheal intubation had cervical myelopathy. We conclude that diffuse/marked PVST swelling, or prior endotracheal intubation, was significantly associated with cervical spinal cord injury (P<0.05). There was no statistically significant correlation between minimal or focal PVST swelling and spinal cord injury.

Atypical findings of discordant bone scan and radiographs in transient osteoporosis of the hip : Case report and review of the literature

The authors report atypical findings of discordant bone scans and radiography seen in a patient with transient osteoporosis of the hip (TOH). Presented in the case of a 60-year-old man who had spontaneous onset of left hip pain which worsened for 2 months with weight-bearing on the affected side. Initial and follow-up radiographs of the let hip were normal. Bone scan demonstrated intense uptake of Tc-99m MDP in the affected femoral head and neck, corresponding to characteristics of abnormal signal intensity of TOH or transient bone marrow edema syndrome on MRI. This discordant pattern of bone scan and radiographs has rarely been reported in the literature. Its possible mechanism of causation and clinical implication in TOH, together with a review of the literature, are discussed in this report.

Twenty-four-hour emergency department coverage by attending radiologists

Abstract It has been 5 years since we implemented extended attending radiology coverage at the Ohio State Medical Center. This change in our practice has raised several issues including which cases we should report, the effect on resident education, the impact on our circadian rhythm, and scheduling complexity. As a result of this initiative, the quality of care we provide has improved because of a dramatic decrease in report turn-around time and better consultation with our referring physicians.

Abnormal Cortical Metabolism in Acute Disseminated Encephalomyelitis

A 20-year-old right-handed man awoke with a severe headache and confusion and rapidly developed blurred vision, slurred speech, and right-sided hemiparesis. Initial MRI demonstrated a large demyelinating lesion involving white matter of the left parieto-occipital region with normal cortex and spinal cord. After stereotactic brain biopsy yielded a nondiagnostic specimen, FDG PET scan was performed and showed marked hypometabolism of the left parieto-occipital lobe with diaschisis of the contralateral cerebellum. Acute disseminated encephalomyelitis (ADME) was confirmed by means of a lumbar puncture showing elevated myelin basic protein in the cerebrospinal fluid. A follow-up MRI showed no new white matter lesions after 6 months, and he responded to steroid treatment. The patient recovered completely.

The role of stress radiographs for the severe ankle sprain: A 7-year prospective study

Ankle sprains are common. They are the most common musculoskeletal injury in athletes and account for about 2 million emergency department visits annually in the United States. Although ankle radiographs are often indicated to rule out fractures of the acutely sprained ankle, the need for additional imaging work-up, such as stress radiographs, to evaluate the severity of ligamentous injury is not clear. One hundred five patients with severe ankle sprains diagnosed by stress radiographs were randomized into three conservative modes of therapy (Schantz wrap, cast brace, cast) and followed prospectively for 7 years. There was no statistically significant difference among treatment groups for mechanical outcome at 1 year (P=0.27) or for functional outcome at 5 years (P=0.39) and 7 years (P=0.27) after injury. We conclude that: (a) there currently is no recommendation for stress radiographs in the setting of the acutely sprained ankle, and (b) a larger multicenter study is needed to confirm these findings.

Influence of medicolegal factors in the use of cervical spine and head computed tomographic examinations in an emergency setting

Estimates suggest that defensive medicine, including radiologic studies, costs Americans more than

Sternal fractures: New perspectives

21 billion annually. As a result of our prior evaluation of 13,228 emergency department patients, we already knew that cervical spine and head computed tomographic examinations were the third and fourth most commonly ordered studies in our emergency department. The emergency medicine, obstetrics/gynecology, surgery, and internal medicine physicians at The Ohio State University agreed to cooperate in a study to determine the factors that influence the decision to order these examinations. Overall, 26 (28%) of the physicians surveyed had personal experience in a medical malpractice lawsuit. Attending physicians in all groups were more concerned about potential medicolegal consequences, compared to residents and fellows (P=0.055) when ordering cervical spine examinations. This coincides with the finding that attending physicians were more likely to have been sued (P<0.001). Emergency medicine physicians were more likely to order one of these examinations if the patient had demanded or requested it (P<0.001) and were more likely to weight physical examination findings more heavily (P=0.007) when compared to other physician groups. Finally, all physician groups combined suggested that approximately 33% of all cervical spine and 39% of all head computed tomographic examinations could be avoided if there were no worries about medicolegal consequences.

Rural teleradiology initiative: Accuracy of interpretation in the emergency setting

Acute sternal fractures occur in the setting of severe deceleration. The authors propose that the displacement in a sternal fracture can point to the mechanism and thus to associated injuries that should be considered. Stress fractures of the sternum follow a predictable pattern that mirrors the acute indirect sternal injury, i.e., hyperflexion of the thoracic cupula. The authors propose that this thoracic cupula acts as a unit in hyperflexion of the upper thoracic spine and signals severe deceleration with likely posterior shears of aorta, spine, cord, and lungs. The lower sternal depression, conversely, points toward more anterior compression with heart and anterior lung at risk. Thus, the direction of the sternal fracture displacement yields valuable information about the mechanics of injury. Including the sternum on lateral C-spine and T-spine films fills an important gap in our understanding the mechanism of thoracic trauma.