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SET T0002 -
Emergency Department

CASE 1

HISTORY	HISTORY Patient fell down a long flight of stairs. Painful neck.
QUESTION	QUESTION Normal or abnormal?
RADIOGRAPHS	RADIOGRAPHS
ANSWER	ANSWER VIEW Fracture of the posterior arch of the C2 vertebra with slight forward subluxation of C2 on the C3 vertebra. The arch fracture is a type of Hangman's fracture. Note the additional fracture involving the anterior cortex of C2 vertebra. *See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Page 186* NB This radiograph is not satisfactory in terms of technique. The cardinal rule is that "on the lateral radiograph the top of T1 vertebra must be visible". Sometimes it is technically impossible to show the top of the T1 vertebra on the lateral radiograph; in which case further imaging is necessary (such as CT).

CASE 2

HISTORY	HISTORY Recent onset of a cough and fever. Clinically - this patient has developed a pneumonia.
QUESTION	QUESTION Which lobe is affected? How can you be very precise in terms of the anatomical location ?
RADIOGRAPHS	RADIOGRAPHS
ANSWER	ANSWER VIEW The pneumonia affects the left upper lobe. It does not affect the lower lobe. Precise location is possible by applying the Silhouette Sign to the shadow projected over the lower zone of the left lung. Silhouette Sign . . . *See : The Chest X-Ray : A Survival Guide : Pages 45-50*

CASE 3

HISTORY	HISTORY Painful shoulder. Patient is a kitchen fitter and he received a severe electric shock at work today.
QUESTION	QUESTION This is a single " second view " of the shoulder. The other view that was obtained ( the AP radiograph ) is not provided because we want you to answer questions in relation to the " second view ". When a shoulder is injured, two radiographs will be obtained : an AP radiograph and a second view. In general, there are three technically different second views to choose from. Can you name them? Which " second view " is shown here? Can you identify and name and describe the different bones and alignments on this radiograph? What major abnormality do you detect on this radiograph?
RADIOGRAPHS	RADIOGRAPHS
ANSWER	ANSWER VIEW There are three very different " second views " available to the Emergency Department (ED). Specifically: The Axial (ie a cephalo-caudal) view. Sometimes also referred to as the cruel, cruel, view. The " Y " view ( in effect, a lateral scapula view ). The Apical Oblique view. 2. The view shown here is an Apical Oblique view. It is our preferred second view. 3. If you have any difficulty in identifying the various anatomical landmarks on this radiograph . . . *See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages 76,79* 4. This view shows - very clearly - a posterior dislocation of the head of the humerus. This is the major finding. (Also, note the old Hill Sach's lesion on the posterior and lateral aspect of the head of the humerus. See today's Case 4).

CASE 4

HISTORY	HISTORY Rugby player. Over the years he has dislocated his right shoulder several times. Today he presents once again to the ED with pain in the shoulder.
QUESTION	QUESTION We want you to concentrate on evaluating this second view. Which one of the available second views is shown here? Do you know how the patient was positioned when this radiograph was obtained? (That knowledge will assist you in understanding the anatomical alignments - both normal and abnormal). What does this radiograph show?
RADIOGRAPHS	RADIOGRAPHS
ANSWER	ANSWER VIEW This is an Apical Oblique radiograph. Patient positioning? Philip Wilson, the medical artist, shows you how the patient was / is positioned . . . *See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Pages xx* 3. Excellent demontration of the following: No dislocation. Alignment at the gleno-humeral joint is anatomical. Contrast the gleno-humeral joint alignment shown here with the alignment shown in Case 3. The defect in the postero-lateral aspect of the head of the humerus is a Hill-Sachs lesion. It represents a compression fracture. This is a fairly common complication with an anterior dislocation at the shoulder joint. *See : Accident & Emergency Radiology : A Survival Guide (3rd edition) : Page 85*

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