Author: Carlos Cevallos

Wednesday Image Review

What is the diagnosis? By Dr. Westlake

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65 year old M presents with significant swelling, discoloration and pain to the right scrotum and penis after inguinal hernia repair 2 days prior. On exam, patient with ecchymosis and erythema of the right testicle and shaft of the penis. There is significant swelling in the inguinal canal, which is not compressible or reducible. You take the ultrasound to bedside to see: 

What is the diagnosis? 

Answer: Scrotal hematoma 

Differentials for this patient include hematoma, hydrocele, scrotal abscess or infection, failure of mesh causing strangulated or incarcerated hernia.

On imaging, you see mixed echogenic fluid collection with no vascular flow noted. This extends from the right groin into the scrotum, with hypoechogenic fluid tracking around bilateral testicles. This is consistent with a scrotal hematoma. There is no bowel noted, ruling out strangulated or incarcerated hernia. There is no “swirl” sign which would be more consistent with scrotal abscess/infection. The mixed echogenic fluid is most consistent with hematoma rather than hydrocele. 

Pearls for the bedside scrotal ultrasound: 

  • Use the linear probe
  • Place the patient supine, place a towel under the scrotum and drape the patient appropriately
  • Obtain imaging of the unaffected side first for landmarks and comparison
  • Compare to the affected side, noting echogenicity and landmarks
  • Visualize both testicles in the same view 
  • Can utilize doppler to assess for flow in concerns for torsion 

References: 

CT and radiology ultrasound imaging from case are below: 

Wednesday Image Review

What is the diagnosis? By Dr. Cevallos

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A 38 year old male presents to the ED with a chief complaint of right wrist pain that began after a fall off a motorcycle the day prior. On exam, the patient is noted to have tenderness along his right distal radius, snuffbox tenderness, wrist swelling, and is unable to flex/extend the wrist. Normal pulses and sensation is present.

Wrist X-rays demonstrate the following:

What is the diagnosis?

Perilunate dislocation, scaphoid fracture, radial styloid fracture

Perilunate Dislocation:

  • Occur due to a high energy traumatic injury
  • Multiple wrist ligaments are injured with resultant dislocation of the capitate dorsally
  • Often associated with fractures of the radius, ulnar, or carpal bones
  • Imaging:
    • Lunate stays in place, dislocated bone is actually the capitate!
    • AP/PA XR may demonstrate “piece-of-pie” sign: triangular appearance of the lunate (yellow arrow)
    • Lateral XR: Proximal and dorsal displacement of the capitate (yellow arrow) with volar displacement of the lunate (green arrow).
      • The lunate remains articulated with the radius differentiating it from a lunate dislocation (lunate dislocation would have a “spilled-teacup” sign)
  • Management:
    • Emergent closed reduction is indicated to minimize complications such as: median nerve injury, cartilage damage, wrist function issues
    • Sugar-tong splint
    • Urgent orthopedic follow-up as most will require surgical fixation

References: 

Cheffers M. Wrist Reduction Techniques. In: Johnson W, Nordt S, Mattu A and Swadron S, eds. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recoPqKOBgkCSHesR/Wrist-Reduction-Techniques#h.493xci6kkby6. Updated December 21, 2022. Accessed August 15, 2024.

Mark Karadsheh. “Lunate Dislocation (Perilunate Dissociation).” Orthobullets, 5 Nov. 2022, www.orthobullets.com/hand/6045/lunate-dislocation-perilunate-dissociation. “Solution to Unknown Case #30 – Perilunate Dislocation.” RADIOLOGYPICS.COM, 6 Jan. 2014, radiologypics.com/2013/03/28/perilunate-dislocation/.

Wednesday Image Review

What is the Diagnosis? By Dr. Allison Cash

Carlos CevallosLeave a comment

Case: 38 y/o female with a history of bilateral renal stones and recent lithotripsy for renal stone who presented with left flank pain and nausea. Symptoms were consistent with previous renal colic symptoms. Following lithotripsy, the patient had resolution of symptoms before flank pain and nausea returned 3 days ago. Vitals BP 142/97, Pulse 93, Temp 98.1 °F (36.7 °C) (Oral), Resp 18, SpO2 99%. The physical exam demonstrated left sided abdominal tenderness and left CVA tenderness. Bedside ultrasound findings below.

Answer: Ureteral stone at the left UPJ with mild-moderate left hydronephrosis

Ultrasound findings in nephrolithiasis

Hyperechoic foci with posterior acoustic shadowing

  • Location of stone can help predict the probability of spontaneous passage of the stone. Stones in the distal ureter or UPJ are more likely to pass.
  • Size of stone can help predict the probability of spontaneous passage as well

Hydronephrosis

  • Greater degree of hydronephrosis reflects more obstruction of ureter and may indicate need for further imaging or procedural intervention

Twinkle Sign

  • Intense alternating color signal behind calcifications and stones.
  •  Highly suggestive of a kidney stone (sensitivity 99.12%, specificity 90.91%, PPV 99.12%, NPV 90.91%)

Ureteral jets

  • Representing maintained ureteral flow with color Doppler
  • Some studies suggest it can predict spontaneous passage of distal ureteral stones

Conclusions:

Ultrasound can be used first-line for imaging to assess for renal stones, though may require follow-up imaging

Ultrasound may prevent repeated radiation exposure with CT in patients with known renal stones

Bedside US can allow for rapid diagnosis and treatment as well as faster discharge when assessing for renal stones

References:

1. Coursey CA, Casalino DD, Remer EM, Arellano RS, Bishoff JT, Dighe M, et al. ACR Appropriateness Criteria® acute onset flank pain–suspicion of stone disease. Ultrasound Q. 2012 Sep. 28 (3):227-33

2. Dillman JR, Kappil M, Weadock WJ, Rubin JM, Platt JF, DiPietro MA, Bude RO. Sonographic twinkling artifact for renal calculus detection: correlation with CT. Radiology. 2011 Jun;259(3):911-6. doi: 10.1148/radiol.11102128. Epub 2011 Apr 1. PMID: 21460031.

4. Gliga, M. L., Chirila, C. N., Podeanu, D. M., Imola, T., Voicu, S. L., Gliga, M. G., & Gliga, P. M. (2017). Twinkle, twinkle little stone: an artifact improves the ultrasound performance! Medical Ultrasonography, 19(3), 272-275. https://doi.org/10.11152/mu-984

3. Ongun S, Teken A, Yılmaz O, Süleyman S. Can Ureteral Jet Flow Measurement Predict Spontaneous Passage of Distal Ureteral Stones? Urol Int. 2018;101(2):156-160. doi: 10.1159/000490498. Epub 2018 Jun 27. PMID: 29949810.

4. Wong C, Teitge B, Ross M, Young P, Robertson HL, Lang E. The Accuracy and Prognostic Value of Point-of-care Ultrasound for Nephrolithiasis in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2018 Jun;25(6):684-698. doi: 10.1111/acem.13388. Epub 2018 Mar 25. PMID: 29427476.

5. Brisbane W, Bailey MR, Sorensen MD. An overview of kidney stone imaging techniques. Nat Rev Urol. 2016 Nov;13(11):654-662. doi: 10.1038/nrurol.2016.154. Epub 2016 Aug 31. PMID: 27578040; PMCID: PMC5443345.