SET T0024 -
Emergency Department / OPD.

Shadow projected over the right upper zone.

The underlying posterior aspect of the 4th rib is completely absent.

The three most likely possibilities for rib destruction and an accompanying soft tissue shadow (mass) would be: bronchial carcinoma invading the rib, or a rib metastasis, or myeloma.

The appearances are not those of a lung mass and thus it is most likely that this is a rib metastasis or myeloma. A large soft tissue mass is more common with myeloma.

Proven diagnosis: myeloma.

Small, well defined, round lesion projected over the lower zone of the right lung. Smooth margin. No calcification.

A lateral CXR showed the same features and confirmed that the lesion is situated in the lower lobe.

There are no overt malignant features. But there is no earlier CXR for comparison.

This may be a benign granuloma - but a metastasis or a primary bronchial carcinoma can also show this smooth configuration. The shadow, in this patient, must be classified as showing " indeterminate features ".

The patient needs to be advised that further radiological evaluation is now necessary.

[Eventually this lesion was resected : primary bronchial carcinoma].

Analysis of a solitary pulmonary nodule (SPN) detected on a CXR . . .

See : The Chest X-Ray : A Survival Guide : Pages 268-275

This occipito-mental (OM) radiograph is normal.

Are you familiar with the process of examining the four legged stool on an OM view?

Four legged stool??

See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages 58-61

The right side of the midface is normal. All of the components of the four legged stool appear to be anatomical and intact.

The left side of the midface is very abnormal. All four legs of the stool are abnormal :

• Zygomatic arch - fracture.
• Inferior wall of the orbit - fracture.
• Lateral wall of the maxillary antrum - fracture.
• Zygomatico-frontal synchondrosis slightly wide.

These are the features of a Tripod fracture.

Tripod fracture - or would a purist refer to it as a Quadripod fracture??

See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages 58-61,63