Stephen F. Hatem

Amyand’s hernia: a case report of prospective ct diagnosis in the emergency department

The diagnosis of Amyand’s hernia, the development of acute appendicits within an inguinal hernia, is rarely made preoperatively and is often confused clinically with an incarcerated right inguinal hernia. The use of CT to prospectively diagnose Amyand’s hernia and corresponding imaging findings are not well described in the literature. We report a case of Amyand’s hernia, which was correctly diagnosed by CT in a female patient presented to the emergency department with right lower quadrant pain and clinical suspicion of a strangulated omentocele.

Imaging of Lisfranc Injury and Midfoot Sprain

Injuries to the tarsometatarsal joint and of the Lisfranc ligament present a challenge. They are difficult to diagnose and outcomes worsen as diagnosis is delayed. As a result, radiologists and clinicians must have a clear understanding of the relevant nomenclature, anatomy, injury mechanisms, and imaging findings.

Posterior humeral avulsion of the glenohumeral ligament as a cause of posterior shoulder instability. A case report.

Traumatic forces applied to the shoulder during sports activities often result in glenohumeral instability. Frequently, the main reason for instability is the lack of soft-tissue restraint to the translation of the humeral head on the glenoid. Approximately 5% of the cases of glenohumeral instability have been reported to involve posterior instability of the shoulder1. Studies have shown that posterior instability has several soft-tissue-related etiologies, including capsulolabral detachment, capsular laxity, and rotator interval lesions1,2. Anterior avulsion of the humeral attachment of the glenohumeral ligaments has been shown to account for 7.5% (forty-one of 547) to 9.4% (six of sixty-four) of the cases of anterior instability3,4. To date, the case of one patient who was treated because of posterior humeral avulsion of the glenohumeral capsule has been reported in the orthopaedic literature and two series of such patients without reference to treatment have been reported in the radiology literature5,6. In the present report, we describe the case of a patient who had traumatic posterior glenohumeral instability secondary to humeral detachment of the posterior capsule and the posterior portion of the inferior glenohumeral ligament. Arthroscopic repair of this posterior lesion resulted in a successful outcome. Our patient was informed that data concerning the case would be submitted for publication. Anineteen-year-old, left-hand-dominant man presented to our clinic with a two-year history of intermittent clicking and pain in the left shoulder. The symptoms started after he sustained a blow to the anterior aspect of the left shoulder while trying to tackle another player during a high-school football game. The patient reported that the left shoulder had slipped out of place and then spontaneously returned to its normal position. Since then, he continued to experience intermittent clicking, pain, and “looseness” of the …

Diabetic muscle infarction: a rare complication of advanced diabetes mellitus

Diabetic muscle infarction is a rare complication of diabetes mellitus first described in 1965. It typically arises in patients with long-standing diabetes mellitus who have complications of the disease, including nephropathy, retinopathy, and neuropathy. It typically presents with acute onset of thigh pain with an associated palpable tender mass. Recurrent episodes in the same or opposite limb are common. Laboratory evaluation does not generally show any consistent abnormality except for poor glucose control. Histologic features of diabetic muscle infarction consist of large areas of muscle necrosis and edema. Magnetic resonance imaging (MRI) findings in patients without clinical evidence of infection may be typical enough to make tissue biopsy unnecessary. In the appropriate clinical setting, MRI may obviate invasive testing and is the preferred imaging modality. Treatment is supportive with analgesics, rest, and immobilization.

What is the Diagnostic Accuracy of Aspirations Performed on Hips With Antibiotic Cement Spacers

BackgroundPeriprosthetic joint infection is a serious complication after THA and commonly is treated with a two-stage revision. Antibiotic-eluting cement spacers are placed for local delivery of antibiotics. Aspirations may be performed before the second-stage reimplantation for identification of persistent infection. However, limited data exist regarding the diagnostic parameters of synovial fluid aspiration with or without saline lavage from a hip with an antibiotic-loaded cement spacer.Questions/purposesWe asked: (1) For hips with antibiotic cement spacers, does saline lavage influence the diagnostic validity of aspirations? (2) What is the diagnostic accuracy of preoperative aspirations performed on hips with antibiotic cement spacers using the Musculoskeletal Infection Society (MSIS) criteria, stratified by saline and nonlavage? (3) For hips with antibiotic spacers, what are the optimal thresholds for synovial fluid white blood cell (WBC) count and polymorphonuclear neutrophil (PMN) percentage for diagnosing infections?MethodsOne hundred seventy-four hips (155 patients) with antibiotic-eluting cement spacers inserted between October 2012 and July 2015 were reviewed. Of these, 98 hips (80 patients) met the inclusion criteria and were included in the analysis (77 nonlavage, 21 saline lavage aspirations). Laboratory data from the aspiration and preoperative workup and intraoperative details were collected. Infection status of each hip procedure was determined based on a modified MSIS criteria using serologic, histologic, and intraoperative findings (sinus tract communicating with the joint at surgery or two positive intraoperative periprosthetic cultures with the same organism or two of the three following criteria: elevated erythrocyte sedimentation rate [ESR] [> 30 mm/hour] and C-reactive protein [CRP] [> 10 mg/L], a single positive intraoperative periprosthetic tissue culture, or a positive histologic analysis of periprosthetic tissue [> 5 neutrophils per high power field]). The diagnostic parameters were calculated for the MSIS criteria thresholds for synovial fluid (ie, WBC count > 3000 cells/µL and PMN percentage > 80%). Optimal thresholds were calculated for the corrected synovial WBC count and PMN percentage with a receiver operating characteristic curve. Separate analyses were performed for the hips with successful aspirations (nonlavage group) and those with saline lavage aspirations.ResultsThe WBC count and PMN percentage were higher in hips with infection than in hips without infection when nonlavage aspirations were done (WBC count, 6680 cells/µL ± 6980 cells/µL vs 2001 ± 4825; mean difference, 4679; 95% CI, 923-8436; p = 0.015; PMN percentage, 83% ± 13% vs 44% ± 30%; mean difference, 39%; 95% CI, 39%–49%; p < 0.001) and the findings between infected and noninfected aspirations were not different when saline lavage aspirations were done (WBC count, 782 cells/µL ± 696 vs 307 cells/µL ± 343; mean difference, 475; 95% CI, −253 to 1203; p = 0.161; PMN percentage, 67% ± 15% vs 58% ± 28%; mean difference, 10%; 95% CI, −11% to 30%; p = 0.331). Aspirations performed without lavage yielded good diagnostic accuracy in all parameters (WBC count, 78% [95% CI, 70%–86%]; PMN percentage. 79% [95% CI, 70%–88%]; positive culture: 84% [95% CI, 81%–90%]; at least one of the above: 79% [95% CI, 70%–88%]); but in the saline lavage group, none had WBC counts above the threshold (diagnostic accuracies for WBC count, 0%; PMN percentage, 71% [95% CI, 62%–86%]; positive culture, 76% [95% CI, 76%–86%]; at least one: 71% [95% CI, 57%–91%]). Because saline lavage did not result in differences between aspirations from infected and noninfected hips, we calculated the optimal thresholds in the nonlavage group only; the optimal threshold for synovial WBC count was 1166 cells/µL and for synovial PMN the percentage was 68%, which corresponds to WBC count diagnostic accuracy of 78% (95% CI, 69%–87%) and PMN percentage accuracy of 78% (95% CI, 69%–87%).ConclusionsBecause the MSIS criteria thresholds resulted in suboptimal sensitivities owing to a higher number of false negatives, we recommend considering lower WBC count and PMN percentage thresholds for hip-spacer aspirations. Furthermore, the WBC count and PMN percentage results from aspirations performed with saline lavage are not reliable for treatment decisions.Level of EvidenceLevel III, diagnostic study.

Markedly elevated lipase as a clue to diagnosis of small bowel obstruction after gastric bypass.

We describe an afferent loop obstruction in a patient who had a subtotal gastrectomy with Roux-en Y gastrojejunostomy for postvagotomy syndrome. The clinical presentation and initial studies suggested acute pancreatitis. A computed tomography scan showed a small bowel obstruction distal to the jejunojejunal anastomosis. The patient was taken to the operating room for an exploratory laparotomy, lysis of adhesions, and closure of her jejunostomy. Surgery was successful at resolving her obstruction. In any Roux-en-Y gastric reconstruction or gastric bypass patient presenting to the emergency department with abdominal pain and elevated transamines or pancreatic enzymes, a small bowel obstruction must be considered. Additional imaging with a computed tomography scan is advocated, as well as surgical consultation.

Looking back, moving forward: 1988–2013. The first 25 years of the American Society of Emergency Radiology

The American Society of Emergency Radiology (ASER) was founded in 1988 and is celebrating its 25th Anniversary. ASER is thriving and emergency radiology has never enjoyed greater popularity than at present. This history describes the genesis of the Society, its growth and current state of affairs. It is based on the recollections and personal files of the authors, one Founder and both former ASER Presidents and Gold Medalists, the ASER archives, and interviews and correspondence with many ASER members. It is hoped that this brief review will be interesting to the reader, provide some insight into ASER evolution over the years, and hold some lessons moving forward.

Cases from the Cleveland Clinic: cerebral venous sinus thrombosis presenting to the emergency department with worst headache of life

A 31 year old woman presented with the worst headache of her life and was diagnosed with cerebral venous sinus thrombosis (CVST) by routine unenhanced computed tomography (CT) scan, subsequently confirmed with magnetic resonance imaging (MRI) and magnetic resonance venography (MRV). Awareness of this less common cause for acute neurological presentation in the Emergency setting is important; the imaging characteristics of CVST are reviewed.

Segmental omental infarction

Acute right-sided abdominal pain is a common presenting symptom in the emergency department. Acute cholecystitis and acute appendicitis are the most likely etiologies for right upper and lower quadrant pain, respectively. However, other differential possibilities include right-sided diverticulitis and perforated colon carcinoma. This case report of an 18-year-old man with segmental omental infarction highlights a much less frequent, self-limited cause of right-sided abdominal pain, which is increasingly identified on computed tomography scans.

Renal medullary carcinoma: unsuspected diagnosis at stone protocol CT

Renal medullary carcinoma (RMC) is an aggressive neoplasm occurring almost exclusively in adolescents and young adults with sickle cell (SC) hemoglobinopathies, usually sickle cell trait (SCT) or hemoglobin SC disease. The most common presentations are hematuria and flank or abdominal pain. It is a highly malignant tumor, and responses to chemotherapy are rare and transient resulting in a dismal prognosis. A high level of suspicion is necessary when evaluating at risk patients presenting with hematuria or flank pain, as currently it appears that only early diagnosis could potentially alter the outcome of this disease. We report a case of RMC in a young male patient with SCT, who presented to the emergency department with low back pain and microscopic hematuria, clinically mimicking acute obstructing urolithiasis. Our case emphasizes the need to consider alternate diagnoses when evaluating computed tomography scans for acute flank pain.