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Reflections: Emergency Radiology¹

¹ From the Department of Radiology, University of Texas Medical School, 6431 Fannin, MSB 2.100, Houston, TX 77030. Received May 17, 2000; revision requested June 27; revision received August 7; accepted August 15. Supported in part by a grant from the John S. Dunn Research Foundation. Address correspondence to the author (e-mail: John.H.Harris@uth.tmc.edu).

View larger version (138K): [in a new window]   Figure 1a. (a) Lateral radiograph shows a subtle high (type II) dens fracture (arrow). The fracture (arrows in b and c) is seen to the best advantage on the (b) frontal and (c) lateral polydirectional tomograms.

View larger version (94K): [in a new window]   Figure 1b. (a) Lateral radiograph shows a subtle high (type II) dens fracture (arrow). The fracture (arrows in b and c) is seen to the best advantage on the (b) frontal and (c) lateral polydirectional tomograms.

View larger version (155K): [in a new window]   Figure 1c. (a) Lateral radiograph shows a subtle high (type II) dens fracture (arrow). The fracture (arrows in b and c) is seen to the best advantage on the (b) frontal and (c) lateral polydirectional tomograms.

View larger version (43K): [in a new window]   Figure 2a. Subcapsular splenic injury in a patient with blunt abdominal trauma following a motor vehicle crash. (a) Supine chest radiograph shows the left hemidiaphragm (solid arrow) is slightly elevated—that is, higher than the right—and its margin is indistinct. Minimal compression atelectasis (open arrow) involves the left lower lobe just cephalad to the diaphragm. These subtle changes are suggestive of a splenic injury. (b) Supine abdominal radiograph shows the splenic shadow (*) is enlarged and depresses the splenic flexure (arrows) inferomedially. The gastric air bubble (arrowheads) is displaced medially.

View larger version (158K): [in a new window]   Figure 2b. Subcapsular splenic injury in a patient with blunt abdominal trauma following a motor vehicle crash. (a) Supine chest radiograph shows the left hemidiaphragm (solid arrow) is slightly elevated—that is, higher than the right—and its margin is indistinct. Minimal compression atelectasis (open arrow) involves the left lower lobe just cephalad to the diaphragm. These subtle changes are suggestive of a splenic injury. (b) Supine abdominal radiograph shows the splenic shadow (*) is enlarged and depresses the splenic flexure (arrows) inferomedially. The gastric air bubble (arrowheads) is displaced medially.

View larger version (92K): [in a new window]   Figure 3. Supine radiograph of the abdomen obtained in a patient who sustained blunt right abdominothoracic trauma in a motor vehicle collision shows medial displacement of the entire ascending colon from the flank stripe caused by fluid opacity in the right paracolic gutter (*). The fluid opacity in the right paracolic gutter also obliterates the angle of the liver. In view of the traumatic history, the presumptive diagnosis was ruptured liver and gross hemoperitoneum.

View larger version (151K): [in a new window]   Figure 4. Dog ear sign of fluid in the pelvic peritoneal recess in a patient who sustained major blunt abdominal trauma in a motor vehicle collision. Supine abdominal radiograph shows a full bladder (solid arrows), which represents the face of the dog. The convex soft-tissue opacity representing blood in the left lateral pelvic peritoneal recess (arrowheads) and separated from the bladder by a thin hyperlucent strip of extraperitoneal fat (open arrow) is the dog ear.

View larger version (179K): [in a new window]   Figure 5. Appendicolith. Supine radiograph obtained in a patient with right lower quadrant pain, tenderness, and rebound tenderness and leukocytosis shows an oval opacity (arrows) that was proved to be an appendicolith at surgery.

View larger version (69K): [in a new window]   Figure 6. Supine abdominal radiograph obtained in a child with a 3-day history of generalized abdominal pain and tenderness without right lower quadrant localization shows displacement of the ascending colon (arrowheads) from the flank stripe represented by a soft-tissue opacity (*) that obliterates the angle of the liver. The normal area of hyperlucency of the flank stripe is mottled by transudation from the paracolic gutter through the peritoneum into the extraperitoneal fat of the flank stripe. At surgery, the patient had an appendiceal abscess with free pus in the paracolic gutter.

View larger version (150K): [in a new window]   Figure 7. Transverse CT scan shows direct signs of acute appendicitis, including thickening of the appendiceal wall (arrowhead) and stranding of the periappendicular fat (arrows). The appendix measured 7 mm in diameter.

View larger version (156K): [in a new window]   Figure 8. Transverse CT scan shows characteristics of sigmoid diverticulosis, including diverticula (arrowheads) without signs of inflammation or fibrosis and hypertrophy of the inner circular layers of nonstriated muscle (arrows) with resultant narrowing of the sigmoid colon lumen.

View larger version (117K): [in a new window]   Figure 9. Infusion urogram. The site of left distal ureteral calculus (arrow) was demonstrated at infusion urography on the supine postvoid radiograph obtained 30 minutes following infusion of the contrast material.

View larger version (92K): [in a new window]   Figure 10. Supine urogram obtained in a 12-year-old boy who was accidentally shot, transversely, through the right upper quadrant of the abdomen and epigastrium with a deer rifle at a distance of approximately 50 yards. On arrival at the hospital, he was in deep shock and taken directly to the operating room. The surgeon needed to know whether the patient had two kidneys, their location, and their functional state. In transit to the operating room, infusion urography was performed. This "single-shot" supine urogram answered all questions relative to the urinary tract. The right kidney was intact. The right nephrogram represents the indirect damage to the kidney from the bullet as it passed through the liver. Opacification of each ureter (arrows) confirms bilateral renal function.

View larger version (127K): [in a new window]   Figure 11. Colon cut-off sign. Supine abdominal radiograph obtained in a patient with clinical and laboratory evidence of acute pancreatitis shows focal middle abdominal small-bowel ileus (ie, sentinel loops) and an abrupt termination of air in the left side of the transverse colon (arrows)—that is, the colon cut-off sign.

View larger version (159K): [in a new window]   Figure 12. Supine radiograph obtained in a patient shot in the abdomen demonstrates a vague, ill-defined, obliquely oriented opacity (arrowheads) in the right upper quadrant, which represents the falciform ligament outlined by free air in the peritoneal space.

View larger version (113K): [in a new window]   Figure 13. Supine radiograph shows a massive pneumoperitoneum manifested by intra- and extraluminal air outlining the mucosal and serosal surfaces, respectively, of the small (arrowheads) and large (arrows) intestines—that is, the Rigler sign (17).

View larger version (106K): [in a new window]   Figure 14. Transverse contrast-enhanced CT scan shows acute traumatic aortic tear. The curvilinear defect (straight arrow) in the lumen of the aorta represents the actual tear through the intima and muscularis of the aortic wall. The pseudoaneurysm is indicated by the curved arrow. Fluid (*) is present in each pleural space.

View larger version (114K): [in a new window]   Figure 15a. Pantopaque myelogram shows an epidural leak of contrast material (arrows) on the (a) anteroposterior and (b) lateral projections. Note the needle remaining in the subarachnoid space for removal of the oil-based contrast material.

View larger version (113K): [in a new window]   Figure 15b. Pantopaque myelogram shows an epidural leak of contrast material (arrows) on the (a) anteroposterior and (b) lateral projections. Note the needle remaining in the subarachnoid space for removal of the oil-based contrast material.

View larger version (136K): [in a new window]   Figure 16. Lateral radiograph of the skull shows a nondepressed skull fracture (arrows) crossing the course of the anterior division of the middle meningeal artery adjacent to the coronal suture.