Diagnosis of scaphoid fractures. Are plain radiographs reliable?

Clinical Scenario

It’s a busy wednesday morning in ED. 

A 18 yo guy presents with the right hand upraised and dressed. 

In the other hand he has a bundle of X ray.   

“About ten days ago, it was a Saturday night, I was with my new girl-friend. Hitting a punch bag as hard as possible I felt pain to my right wrist. My doctor ordered wrist X ray. It’s not broken, he says, but I’m very afraid, when I move the wrist  it pains me so much”.

On clinical examination there is snuff box tenderness, the axial loading maneuvre on the thumb is positive (see previous post). 

The emergency phisician takes an accurately look at the X rays. They are of high quality, the study had 4 views of the scaphoid, there’s no evidence of irregularity of cortex, the scaphoid fat pad seems normal.

“Repeat X-ray” orders the doctor….

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Plain X ray in suspected bowel obstruction. Is that all?

Clinical Scenario

A 67 y/o woman arrives in the ED at 5pm because of diffused abdominal pain since 2 hours. She has nausea and she refers costipation from the day before. 

She has a history of hysterectomy 5 years before because of fibroma.

Vital signs are normal, she presents pale and sufferer for pain, the abdomen is distendend and palpation cause pain all over it. 

Bowel movements are present but abnormal. 

Plain x ray shows 2 little fluid levels without the evidence of dilated loops of bowel, so radiologist describe it as negative.

Has plain x ray changed your previous clinical judgment about the suspect of bowel obstruction?

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Is chest X ray necessary to rule out PNX after thoracic maneuvers?

Clinical Scenario

It’s a busy day in ED this morning. 

The first patient refers dyspnoea, he has an advanced pulmonary neoplasia, ultrasound and chest x-ray confirm that the left zone is occupated by a pleural effusion. The thoracentesis removes about 1.5 liter of fluid, the patient breathes easily.

The second patient is 65 yo, he has pneumonia, he is septic, it’s impossible to find a vein, the right internal jugular vein is identified by ultrasound and the catheterization is performed without any problem.   

Is it necessary in this cases to perform a chest  X-ray to rule out a PNX?

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Pleuritic Pain, the end of the saga...

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain on the left in basal region. The pain is described as stabbing, well localized, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. 

Chest x ray is normal. You receive blood test: WBC 7.500/mcL, CRP 20 mg/dl , D-dimer 603 ng/ml

We have seen in the previous post that we can’t rule out the possibility to find a radio-occult lesion based on our blood test, but on the other hand specificity is poor, so what are we looking for?

What does pleuritic pain means? 

If you ask wikipedia… the answer is frightful…

What if you ask to your probe?

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What does it hide behind a negative X-Ray?

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain on the left in basal region. The pain is described as stabbing, well localized, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. 

Chest x ray is normal. You receive blood test: WBC 7.500/mcL, CRP 20 mg/dl , D-dimer 603 ng/ml.

Maybe is not a wall chest pain, but in which direction this test are carrying you?

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Pleuritic pain and radio-occult lesion

Clinical Scenario

A 33 y/o woman, comes to the ED because of a sudden emithorax pain localized on the left in basal region. The pain is described as stabbing, well localised, it worsen with inspirium …a pleuritic pain, no cough, no fever, not hemoptysis. She smokes, she does not take any medication. Chest x ray is normal. 

Is it a wall chest pain or there migth be something else? 

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Can Ultrasound rule out a pneumothorax?

Clinical Scenario

You are allerted for a level 3 trauma from the mountain, a cyclist has fallen going down hill.

You prepar the shock room with everything you may need, dress up, and wait.

A 25 y/o cyclist arrives completely immobilized, you immidiately start to  perform ABCDE as you learned in your recent ATLS course (you feel confident).

First stop is a possible problem in “B” (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. …you go on….in “E” (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic…ect…

FAST is normal. You ask for X-Ray : anteroposterior (AP) chest x-ray, pelvis and thigh bone. Confirmed exposed fracture, no signs of pneumothorax, surgery room is ready…

You recently have reeded the previous post and you don't feel confident about a negative thorax x ray, so you decide to “extend” your FAST and on the right emithorax you find a "lung point"...

are you going to let this patient be intubated?

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Thoracic trauma and chest X-Ray

Clinical Scenario

You are alerted for a level 3 trauma coming from the mountain, a cyclist has fallen going down hill.

You prepare the shock room with everything you may need, dress up, and wait.

A 25 y/o cyclist arrives completely immobilized, you immediately start to  perform ABCDE as you learned in your recent ATLS course (...you feel confident).

First stop is a possible problem in “B” (breathing): he has an ecchimosis on the right emithorax, not crepitation, maybe there is a less vescicular murmur on the same side, but you are not sure (the shock room is very crowded an noisy!), he is slightely tachypnoic (RR is 24), O2 saturation is 96%. …you go on….in “E” (Exposure) you find an exposed, bleeding, thigh bone fracture that surly is going to need surgery, at the moment you stop the bleeding, stabilize, allert orthopedic…ect…

FAST is normal. You ask for X-Ray: anteroposterior (AP) chest x-ray, pelvis and thigh bone. Radiologist confirms exposed fracture, no signs of pneumothorax, surgery room is ready...

…Do you still feel confident?

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Is CRP correlated to CT result in the evaluation of abdominal pain?

A 74 yo/man complained of diffuse abdominal pain. The pain was intermittent and accompained by vomiting. He has no history of abdominal pain or abdominal surgery.

On examinations the patient presented non icteric, afebrile, not tachicardic. 

The abdomen was mildly distensed with midline tenderness. 

The US evidenced a normal aorta diameter. 

Abdominal x ray showed non specific bowel gas pattern. 

CRP value was 7 mg/L.

The radiologist says it is a little value to perform an abdominal CT, we see tomorrow…..

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Diagnosis of pneumonia. Is it the time for a combined imaging strategy?

A 80 yo man is brought from an assisted-living facility because of fever, productive cough, tachycardia and dyspnoea. 

He has a history of dementia and hypertension.

He is cachectic, you hear ronchi on the left side. 

How should you approach this patient?

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