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29M with right wrist pain and deformity after a motorcycle accident • Xray of the Week Figure 1. Describe the wrist injury. Figure 2. Transscaphoid perilunate dislocation. Frontal , lateral, oblique radiographs of the wrist. Red arrow points to scaphoid fracture and yellow arrow points to a normally positioned lunate bone. 2A. On the frontal view, the capitolunate joint space is obliterated as the bones overlap one another. 2B. On the lateral view the capitate (green arrow) is dislocated dorsal to the lunate (yellow arrow). Due to the fracture (red arrow), the proximal pole of the scaphoid has remained aligned with the lunate, whereas the distal pole has followed the capitate dorsally. The lunate and the distal radius remain normally aligned. Discussion: Of the eight carpal bones that make up the wrist, the scaphoid bone is fractured most often and accounts for 70% of all carpal fractures.[1] Less commonly, scaphoid fractures can be associated with perilunate dislocations. The injury mechanism in transscaphoid perilunate dislocations is typically “high energy” with wrist hyperextension (e.g. falling from a height, sports trauma, and motor vehicle accidents). These patients generally present with exquisite wrist pain and swelling, exacerbated by wrist motion.[2] Figure 3. Mayfield Classification of Carpal Dislocations from https://wikem.org/wiki/Perilunate_and_lunate_dislocations Carpal dislocations have been described to occur in 4 stages (Fig. 3) [3]. In a Stage I injury, the scapholunate joint is disrupted. A Stage II injury finds the capitolunate joint disrupted, and Stage III injury is disruption of the lunotriquetral joint. It is considered a Stage IV injury when there is complete lunate dislocation with volar displacement [2-4]. On PA radiographs, a Stage I scapholunate dissociation can be recognized by the ‘Terry-Thomas sign’ which refers to a gap greater than 2 mm between the scaphoid and lunate bones, and is due to scapholunate ligament rupture. In normal lateral wrist radiographs, the capitate bone is aligned with the lunate bone and sits right above it. As seen in this case, with Mayfield Stage II when perilunate dislocation occurs, the capitate can be identified dorsally with respect to the lunate (Figs. 1B, 2B). This case also has a fracture through the scaphoid which is seen in 60% of cases. With Mayfield Stage III, or midcarpal dislocation there is dislocation of the capitate from the lunate and subluxation of the lunate from the radius. A Stage IV lunate dislocation is characterized by the "spilled teacup" sign seen on lateral radiographs, indicating the volar displacement of the lunate bone resembling a teacup spilling forward [2,5]. (Fig. 4) Transscaphoid perilunate dislocations can be treated with initial closed reduction and splint followed by surgical repair of injured ligaments after swelling has decreased. However, in cases where progressive median nerve dysfunction is noted, immediate open reduction with internal fixation (ORIF) is the preferred treatment [2,6]. Figure 4. Stage IV lunate dislocation. A. PA radiograph of lunate dislocation with triangular, “piece of pie” lunate appearance (green arrows), disruption of carpal arcs, increased radiolunate space, and overlap of lunate with other carpals. B. Lateral radiograph showing the “spilled teacup” appearance of lunate dislocation (yellow arrows), with the concavity of the lunate facing anteriorly. The lunate has volar displacement and angulation, and has lost articulation with the radius and capitate. ​​​​ References: 1. Papp S. Carpal Bone Fractures. Hand Clinics. 2010;26(1):119-127. doi:10.1016/j.hcl.2009.08.014 2. Kannikeswaran N, Sethuraman U. Lunate and perilunate dislocations. Pediatr Emerg Care. 2010;26(12):921-924. doi:10.1097/PEC.0b013e3181fe915b 3. Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: Pathomechanics and progressive perilunar instability. Journal of Hand Surgery. 1980;5(3):226-241. doi:10.1016/S0363-5023(80)80007-4 4. Kennedy A, Allan H. In Brief: Mayfield et al. Classification: Carpal Dislocations and Progressive Perilunar Instability. Clinical Orthopaedics and Related Research. 2012;470(4):1243-1245. doi:10.1007/s11999-012-2275-x 5. Bashir WA, Aziz A, Jidaal I. Imaging of skeletal extremity trauma: A review. Trauma. 2014;16(4):300-317. doi:10.1177/1460408614542920 6. Kloss B, Patierno S, Sullivan A. Transscaphoid perilunate dislocation. International Journal of Emergency Medicine. 2010;3(4):501-502.doi:10.1007/s12245-010-0212-x Nirali Dave is a medical student at Medical University of Lublin in Poland, currently doing clinical rotations in New York. Before that she completed her undergraduate education at Rutgers University, and worked as a medical scribe. Nirali was first exposed to basic radiologic imaging while scribing, and was very quickly taken by the field. Her passion for radiology comes from the bridging of anatomy, health technologies, and patient care. In the future, she hopes to complete a diagnostic radiology residency and stay committed to clinical research and patient education. UPDATE March 19, 2021: Nirali Dave is a resident in Radiology and Imaging Sciences at Indiana University School of Medicine. Follow Nirali Dave on Twitter @ndave08 All posts by Nirali Dave Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

59 yo male who was assaulted and sustained blunt trauma to the left orbit. • Xray of the Week Figure 1. What are the important findings in each image. Figure 2. A: Coronal CT image demonstrates normal contour of the right globe (green arrow) and a shrunken left globe (orange arrow), which is suggestive of globe rupture. B: Axial CT image demonstrates normal contour of the right globe (green arrow) and abnormal contour left globe (orange arrow), suggestive of globe rupture. Note the mushroom shape due to extruded vitreous. The hyperattenuation of the left globe (orange arrow) is consistent with vitreous hemorrhage. C: Sagittal CT image demonstrates normal contour in the right globe (green arrow). D: Sagittal CT image demonstrates a shrunken left globe (orange arrow), which is suggestive of globe rupture. Globe Rupture: Ruptured globes are an ocular emergency that could lead to permanent vision loss if not treated quickly. Penetrating and blunt trauma, in addition to chemical exposure, account for the majority of cases. High intraocular pressure leads to ruptures at weak areas in the eye wall, including rectus muscle insertion sites, the limbus, and the optic nerve.1 Imaging: Computed tomography (CT) is the recommended imaging modality for evaluating orbital trauma. Thin-section axial CT scans followed by multiplanar reformations can visualize ruptured globe contour, which can present as a “mushroom” (Figs. 1-2) or “flat tire” shape.2 Vitreous hemorrhage increases the attenuation of the vitreous on CT as well.3 Other findings of open globe injuries include a thick posterior sclera, hazy globe contour outline, abnormal anterior chamber size, and the presence of intraocular gas or foreign bodies. CT detects open globe injuries with a sensitivity of 90-100%, specificity of 50-80%, and interrater reliability of κ > 60%. 4 Prompt identification of ruptured globes is necessary to guide management. Treatment: Immediate surgery and empiric systemic antibiotics are needed to preserve vision and reduce the risk of intraocular infection.3 Once an open globe rupture is suspected, the patient should remain NPO and wear a protective eye device on the affected eye.5 Additionally, physicians should avoid maneuvers, including lid retraction and tonometry, or systemic medications that increase intraocular pressure.6 A semi-recumbent head position, anti-emetics, pain management, and removal of other stressors help prevent increases in intraocular pressure. Patients with open globe injuries should receive a tetanus booster if their immunization history is uncertain. Surgery on the ruptured globe and removal of ocular foreign objects should be performed once patients are stabilized. Following surgery, patients should begin antibiotic coverage of pathogens associated with endophthalmitis per recommendations provided by their institution’s infectious disease specialist.7 Prognosis: Ruptured globes maintain a poor prognosis. The patient’s presenting visual acuity is a major determinant of their post-surgical visual acuity. The Ocular Trauma Score (OTS) metric proposed by Kuhn et al can be used to determine the functional outcome of injured eyes.8 ​​​​ References: Murata N, Yokogawa H, Kobayashi A, Yamazaki N, Sugiyama K. Clinical features of single and repeated globe rupture after penetrating keratoplasty. Clin Ophthalmol. 2013;7:461-465. doi:10.2147/OPTH.S42117 Kubal WS. Imaging of orbital trauma. Radiographics. 2008;28(6):1729-1739. doi:10.1148/rg.286085523 Zhou Y, DiSclafani M, Jeang L, Shah AA. Open Globe Injuries: Review of Evaluation, Management, and Surgical Pearls. Clin Ophthalmol. 2022;16:2545-2559. doi:10.2147/OPTH.S372011 Crowell EL, Koduri VA, Supsupin EP, et al. Accuracy of Computed Tomography Imaging Criteria in the Diagnosis of Adult Open Globe Injuries by Neuroradiology and Ophthalmology. Acad Emerg Med. 2017;24(9):1072-1079. doi:10.1111/acem.13249 Ritson JE, Welch J. The management of open globe eye injuries: a discussion of the classification, diagnosis and management of open globe eye injuries. J R Nav Med Serv. 2013;99(3):127-130. https://www.ncbi.nlm.nih.gov/pubmed/24511795 Bord SP, Linden J. Trauma to the globe and orbit. Emerg Med Clin North Am. 2008;26(1):97-123, vi - vii. doi:10.1016/j.emc.2007.11.006 Blair K, Alhadi SA, Czyz CN. Globe Rupture. StatPearls Publishing; 2022. Accessed June 5, 2023. https://www.ncbi.nlm.nih.gov/books/NBK551637/ Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. The Ocular Trauma Score (OTS). Ophthalmol Clin North Am. 2002;15(2):163-165, vi. doi:10.1016/s0896-1549(02)00007-x Eric Errampalli is a passionate medical student at the University of Missouri – Kansas City Six-Year BA/MD Program, with a steadfast commitment to becoming a radiologist. His fascination with the field stems from its integral role in healthcare and the endless possibilities for technological advancements waiting to be made. At UMKC, Eric has made significant contributions to the Radiology Interest Group, serving in various executive roles and currently as the interventional radiology chair. His leadership has inspired his peers to explore the field and discover the boundless opportunities for growth and impact. Beyond UMKC, Eric's interests have risen to a national level, as he serves on the Society of Interventional Radiology Medical Student Council Education Committee and TheRadRoom IR Team. Through these platforms, he has been instrumental in shaping the future of interventional radiology education and promoting awareness of the field among medical students. Eric's passion for innovation extends beyond the classroom, as he strives to help drive change in the field of radiology through his medical entrepreneurial ventures. He believes that entrepreneurship can unlock untapped potential in the field and pave the way for transformative breakthroughs that can improve patient outcomes and revolutionize healthcare. To stay up to date on Eric's journey and learn more about his work, follow Eric on Twitter @EricErrampalli and connect with him on LinkedIn www.linkedin.com/in/eric-errampalli/ All posts by Eric Errampalli Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the anatomic variant and why it is important • Xray of the Week Figure 1. CT Scan - Name the anatomic variant and why it is important. Figure 2. Celiacomesenteric trunk. CT Scan - 3D angiogram image shows a common trunk (red arrow) which gives rise to the superior mesenteric artery and the celiac axis. Axial and sagittal CTA images: Superior mesenteric artery (green arrow) and celiac axis (yellow arrow) originating a common trunk. Figure 3. Celiacomesenteric trunk. Sagittal CT Scan and 3D angiogram in a different patient which shows a large common trunk giving rise to the superior mesenteric artery and the celiac axis. Discussion: The celiac trunk classically gives off three main branches: the left gastric, splenic, and common hepatic arteries. In 30% of the population though variations exist and included within these is the incidence of a celiacomesenteric trunk (CMT) in which the superior mesenteric artery (SMA) also branches from a common trunk with the celiac artery (Figs.1-3). The incidence of this anomaly is reported to be 0.5-3.4% (1-3). In total there have been four different types of CMT with the classic type being recognized as a common trunk containing the 3 branches of the celiac artery along with the SMA (2). In even rarer cases, an embryonic anastomotic branch may persist between the celiac and SMA, known as the arc of Buhler (AOB). Enlargement of this anastomosis can occur as can formation of aneurysms leading to occlusion of the celiac artery (5). CTA is often performed in patients undergoing abdominal procedures, and especially those concerning pancreatic, hepatobiliary, and other gastric neoplasms and masses. Multidetector computed tomography angiography (MDCT) remains the superior method for recognizing anatomical variants within the arterial and venous systems (4). It is crucial to identify anatomical variants such as the one described here prior to any open surgical, laparoscopic, or interventional procedures in order to avoid potential complications. ​​​​ References: 1. D’Souza D. Celiac artery | Radiology Reference Article | Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/coeliac-artery?lang=us. Accessed April 13, 2020. 2. Muzio BD. Celiacomesenteric trunk | Radiology Reference Article | Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/coeliacomesenteric-trunk?lang=us. Accessed April 13, 2020. 3. Ramesh Babu CS, Joshi S, Gupta KK, Gupta OP. Celiacomesenteric trunk and its variants a multidetector row computed tomographic study. Journal of the Anatomical Society of India. 2015;64(1):32-41. doi:10.1016/j.jasi.2015.04.007 4. Winston CB, Lee NA, Jarnagin WR, et al. CT Angiography for Delineation of Celiac and Superior Mesenteric Artery Variants in Patients Undergoing Hepatobiliary and Pancreatic Surgery. American Journal of Roentgenology. 2007;189(1):W13-W19. doi:10.2214/AJR.04.1374 5. Kageyama Y, Kokudo T, Amikura K, Miyazaki Y, Takahashi A, Sakamoto H. The arc of Buhler: special considerations when performing pancreaticoduodenectomy. Surg Case Rep. 2016;2. doi:10.1186/s40792-016-0149-2 Neal Shah is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. Prior to medical school, he completed his undergraduate studies at the University of North Carolina at Chapel Hill where he majored in economics and chemistry. During his 4 years there he worked in UNC’s Biomedical Research Imaging Center where he helped develop formulations for iron-oxide nanoparticles used for MRI; it was here that his love for the field of radiology developed. He eventually wishes to also pursue his MBA and hopes to use it to help advance the field of medicine in terms of medical innovation. UPDATE: Dr. Shah is a radiology resident at Vanderbilt Radiology Follow Neal Shah on Twitter @neal_shah17 All posts by Neal Shah Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Fifth finger pain with minor trauma • Xray of the Week Figure 1. Name the lytic lesion in the fifth proximal phalanx and the complication. Figure 2. Magnified view of the enchondroma with pathologic fracture. Note the typical ring and arc calcifications within the expansile, well-circumscribed metaphyseal lytic lesion with minor cortical thinning and endosteal scalloping. Discussion: Enchondromas are benign, cartilage-forming neoplasms of the medullary bone cavity. They are often discovered incidentally on routine imaging, most commonly found in metacarpal and phalanges bones of the hand.(1-4) Enchondromas are generally asymptomatic, however due to the typical location of the lesions even minor trauma may result in pathologic fractures causing pain and swelling.(2) Recognizing radiographic features of this benign bony tumor can help in excluding more aggressive bone malignancies. On radiographic imaging enchondromas are classically recognized as well-circumscribed, metaphyseal lytic lesions with minor cortical thinning and endosteal scalloping. Occasionally calcifications can be seen on xray, particularly in the ‘ring and arc’ or ‘popcorn’ pattern characteristic of chondroid lesions. When an enchondroma presents with a pathologic fracture, cortical expansion may also be seen on imaging.(2,3) Negative radiographic findings such as the absence of periosteal reactions or soft tissue extension distinguish enchondromas from low-grade osteosarcomas.(1) A higher index of suspicion for malignancy may warrant further evaluation with MRI and histopathologic evaluation. Enchondroma treatment is typically reserved for presence of a pathologic fracture, or if there is high risk of fracture in the future. The treatment options include surgical curettage followed by bone graft or filling with synthetic material, and follow-up xrays to detect any recurrence.(4,5)​ ​​​​ References: 1. Larbi A, Viala P, Omoumi P, et al. Cartilaginous tumours and calcified lesions of the hand: a pictorial review. Diagn Interv Imaging. 2013;94(4):395-409. doi:10.1016/j.diii.2013.01.012 2. Santini-Araujo E, Kalil RK, Bertoni F, Park Y-K. Tumors and Tumor-Like Lesions of Bone: Enchondroma. 2nd ed. 2020. Springer International Publishing; 2020. doi:10.1007/978-3-030-28315-5. https://www.springer.com/us/book/9781447172437#otherversion=9781447165774 3. Mcvey MJ, Kettner NW. Pathologic fracture of metacarpal enchondroma: Case study and differential diagnosis. Journal of Manipulative and Physiological Therapeutics. 2002;25(5):340-344. doi:10.1067/mmt.2002.124417 4. Douis H, Saifuddin A. The imaging of cartilaginous bone tumours. I. Benign lesions. Skeletal Radiol. 2012;41 (10): 1195-212. doi:10.1007/s00256-012-1427-0 5. Hakim DN, Pelly T, Kulendran M, Caris JA. Benign tumours of the bone: A review. J Bone Oncol. 2015;4(2):37-41. Published 2015 Mar 2. doi:10.1016/j.jbo.2015.02.001 Nirali Dave is a medical student at Medical University of Lublin in Poland, currently doing clinical rotations in New York. Before that she completed her undergraduate education at Rutgers University, and worked as a medical scribe. Nirali was first exposed to basic radiologic imaging while scribing, and was very quickly taken by the field. Her passion for radiology comes from the bridging of anatomy, health technologies, and patient care. In the future, she hopes to complete a diagnostic radiology residency and stay committed to clinical research and patient education. UPDATE March 19, 2021: Nirali Dave is a resident in Radiology and Imaging Sciences at Indiana University School of Medicine. Follow Nirali Dave on Twitter @ndave08 All posts by Nirali Dave Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

@GlobalRadCME and @KevinRiceMD are posting Free Open Access Medical education for radiology which is also known as #FOAMrad on Twitter. We are also posting interesting cases on LinkedIn and Facebook. According to a blog post on the largest and most visited FOAMrad site - Radiopaedia, the term FOAMrad was coined by the following group of radiologists and radiology trainees: Fiona Pathiraja (@dr_fiona) Matthew Bull (@mattdbull) Vikas Shah (@DrVikasShah) Andrew Dixon (@DrAndrewDixon) Jeremy Jones (@dr_jbj) David Little (@DrDLittle) Lynne Armstrong (@oscarella) Radiopaedia, the largest FOAMrad resource, was founded by Dr. Frank Gaillard in December 2005, and he remains Editor in Chief of Radiopaedia.org. Symplur Radiology Hashtag Ontology by Matt Hawkins (@MattHawkinsMD): Clinical Tags I have the most popular links in blue Hashtag Topic #AbdRad Abdominal Radiology #ChestRad Chest Radiology #CTRad Computed Tomography #CVRad Cardiovascular Imaging #EMRad Emergency Radiology #HNRad Head/Neck Radiology #IRad Vascular Interventional Radiology #IROnc Interventional Oncology #Mammo Mammography #MRI MRI #MSKRad Musculoskeletal Radiology #MSKUS MSK Ultrasound #NeuroRad Neuro Radiology #NucMed Nuclear Medicine #OBRad Obstetrics Radiology #oncorad Oncologic Radiology #PedsRad Pediatric Radiology #USRad Ultrasound Scientific Disciplines I have the most popular links in blue Hashtag Topic #FOAMRad Free and Open Access to Medical Education Radiology #FOAMus Free and Open Access to Medical Education Ultrasound #GlobalRad Global Radiology #HITRad Radiology Informatics #MolRad Molecular Imaging #POCUS Research Related to Point-of-Care US #RadCME CME Offerings in Radiology #RadEcon Radiology Economics #RadHSR Radiology Health Services Research #Radiology Radiology #RadLeaders Radiology Leadership #RadPhys Radiology Physics #RadPolicy Radiology Health Policy #RadQI Radiology Quality Improvement #RadRes Radiology Residency #RadSafety Radiation Safety #TeleRad Teleradiology #radpathmatch Radiologic - Pathologic correlation on Twitter #xrayoftheweek Interesting cases by Radiologists Vikas Shah, MD and Kevin Rice, MD on Twitter Did you see all my Xray of the Week - 2016 Cases? Here they are: Follow us on Twitter ​@GlobalRadCME Follow Dr. Rice on Twitter @KevinRiceMD Follow Dr. Rice on LinkedIn Follow Global Radiology CME on LinkedIn Follow Global Radiology CME on Facebook Kevin Rice, MD serves as the Medical Director of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a Member of Renaissance Imaging Medical Associates. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015 Dr. Rice launched Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD FACR

Global Radiology CME is pleased to announce our President, Dr. Kevin Rice was recently elected a Fellow of The American College of Radiology for his exemplary service and dedication to the ACR and his profession. Dr. Rice is not only an outstanding practicing radiologist and the President of Global Radiology CME, he also devotes time to providing free radiology online education. He has also been mentoring medical students who are interested in pursuing radiology residencies. Author of an extensive online radiology teaching file produced by Global Radiology CME and followed in over 150 countries across the globe, Dr. Rice is well known for sharing his broad knowledge and extensive experience as a practicing radiologist. Dr. Rice has authored or co-authored over 200 radiology cases that can be accessed on the Global Radiology teaching file. As a testament to his broad knowledge base, Dr. Rice has authored cases in Breast Imaging, MSK Imaging, Body Imaging, Cardiac Imaging, Spine Imaging, Interventional Radiology, and Neuroradiology. The only love that supersedes his passion for radiology is time spent with his family. According to Dr. Rice, "I am honored to have been conferred the prestigious title: Fellow of the American College of Radiology (FACR) at ACR 2023. It is all possible due to my family, especially my loving wife Natalie Rice who has sacrificed so much over many years. She has been my guiding light, and I know that it would not have been possible without Natalie by my side." Dr. Rice is on Twitter @KevinRiceMD All posts by Kevin Rice, MD Related articles: Dr. Kevin Rice: Semifinalist for 2016 AuntMinnie.com's Most Effective Radiology Educator Dr. Kevin Rice: Semifinalist for 2021 AuntMinnie.com's Most Effective Radiology Educator Mentored Medical Students Match in Radiology

79 year old male. Back pain and lower extremity weakness after a fall • Xray of the Week Figure 1.What are the important findings in each image. Figure 2. Coronal CT (A) and sagittal CT (B) images demonstrate fracture at the T11-12 level with significant offset (red arrows) causing the neurologic deficit. Note also the extensive ankylosis throughout the spine. Axial CT image (C) demonstrates edema adjacent to the acute fracture (green arrows). Axial CT image (D) shows fused sacroiliac joints (yellow arrows). Ankylosing Spondylitis: Ankylosing spondylitis (AS) is a seronegative spondyloarthropathy and chronic inflammatory disease of the axial skeleton that leads to the partial or complete fusion and rigidity of the spine. The disease triggers the innate immune response to mobilize macrophages, CD4+ T cells, and CD8+ T cells into the paravertebral and sacroiliac entheses.1 Chronic enthesitis erodes the iliac component of the sacroiliac joints and forms vertical syndesmophytes along the spinal ligament or around the annulus fibrosus of intervertebral discs. These syndesmophytes may fuse at the intervertebral discs and vertebral bodies.2 Ossification of vertebral ligaments present as the dagger sign on X-ray, while ossification of the outer fibers of the annulus fibrosus presents as a bamboo spine.3 [Figs. 1,2] These inflammatory changes additionally lead to osteopenic vertebrae and reduced spinal mobility. Chalk stick fracture: Patients with AS should be monitored to prevent serious complications such as chalk stick fractures: a complete separation of fused vertebrae. The fused osteopenic bones in AS increase the rigidity of the bony spinal structure overall and the risk of patients experiencing low-energy fractures.4 Chalk stick fractures may lead to anterior subluxation and narrowing of the spinal canal.5 As in this case, nearly 67% of chalk stick fractures from AS present with neurologic deficits.6 They typically occur in the cervical spine (81%) followed by the thoracic (11%) and lumbar (8%) regions.7 Primary diagnosis of AS involves radiography of sacroiliac joints and symptomatic areas of the spine (Figs. 1,2). Because radiography may not detect early signs of AS, non-enhanced MRI is recommended in identifying early signs of disease.8 ​​​​ References: Van Praet L, Van den Bosch F, Mielants H, Elewaut D. Mucosal inflammation in spondylarthritides: past, present, and future. Curr Rheumatol Rep. 2011;13(5):409-415. doi:10.1007/s11926-011-0198-2 Ward MM, Deodhar A, Gensler LS, et al. 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis Rheumatol. 2019;71(10):1599-1613. doi:10.1002/art.41042 Kumar RR, Jha S, Sharma A. Dagger sign of ankylosing spondylitis. Oxf Med Case Reports. 2019;2019(12):502-503. doi:10.1093/omcr/omz117 Chaudhary SB, Hullinger H, Vives MJ. Management of acute spinal fractures in ankylosing spondylitis. ISRN Rheumatol. 2011;2011:150484. doi:10.5402/2011/150484 Akhaddar A, Salami M. Fracture of the bamboo spine (chronic ankylosing spondylitis) after cervical injury. Pan Afr Med J. 2014;17:113. doi:10.11604/pamj.2014.17.113.3888 Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J. 2009;18(2):145-156. doi:10.1007/s00586-008-0764-0 Skarentzos K, Karamanou G, Chrysafis I, Papagoras C. Chalk-stick fracture in ankylosing spondylitis. Clin Rheumatol. 2020;39(8):2469-2470. doi:10.1007/s10067-020-05117-0 Bernard SA, Kransdorf MJ, Beaman FD, et al. ACR Appropriateness Criteria® Chronic Back Pain Suspected Sacroiliitis-Spondyloarthropathy. J Am Coll Radiol. 2017;14(5):S62-S70. doi:10.1016/j.jacr.2017.01.048 Eric Errampalli is a passionate medical student at the University of Missouri – Kansas City Six-Year BA/MD Program, with a steadfast commitment to becoming a radiologist. His fascination with the field stems from its integral role in healthcare and the endless possibilities for technological advancements waiting to be made. At UMKC, Eric has made significant contributions to the Radiology Interest Group, serving in various executive roles and currently as the interventional radiology chair. His leadership has inspired his peers to explore the field and discover the boundless opportunities for growth and impact. Beyond UMKC, Eric's interests have risen to a national level, as he serves on the Society of Interventional Radiology Medical Student Council Education Committee and TheRadRoom IR Team. Through these platforms, he has been instrumental in shaping the future of interventional radiology education and promoting awareness of the field among medical students. Eric's passion for innovation extends beyond the classroom, as he strives to help drive change in the field of radiology through his medical entrepreneurial ventures. He believes that entrepreneurship can unlock untapped potential in the field and pave the way for transformative breakthroughs that can improve patient outcomes and revolutionize healthcare. To stay up to date on Eric's journey and learn more about his work, follow Eric on Twitter @EricErrampalli and connect with him on LinkedIn www.linkedin.com/in/eric-errampalli/ All posts by Eric Errampalli Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

68M with headache • Xray of the Week Figure 1. What is the important finding on these images. Figure 2. CT of a planum sphenoidale meningioma. A. Axial non contrast CT showing subtle density in midline frontal region (red arrows). B. Coronal non contrast CT showing subtle density in midline frontal region (red arrows). C. Axial CT with contrast showing enhancing midline mass (green arrows). D. Coronal CT with contrast showing enhancing midline mass with a broad base along the planum sphenoidale (green arrows). Introduction: Meningiomas are extra-cranial tumors which are attached to the dura in most cases (1, 4). Around 5-10% of meningiomas are suprasellar, which are subclassified as arising from the planum sphenoidale, tuberculum sellae, diaphragma sellae, and anterior clinoid process (2). Planum sphenoidale meningiomas may have a poor surgical outcome due to the anatomic complexity as they can extend into nearby structures such as the sella turcica, posterior clinoid, and cavernous sinus (3). Discussion: CT is useful since it can demonstrate any meningiomas effect on adjacent bone and in detecting psammoma calcifications (1). On non-contrast CT, meningiomas appear isodense compared to adjacent brain tissue (Figs. 1A, B). On contrast CT, the meningioma will enhance and may or may not appear homogeneous (Fig. 1C, D) depending on the presence of calcium, fat, and tumor necrosis (2). Hyperostosis of adjacent bone suggests a benign meningioma. MRI has the ability to assess soft tissue characteristics including vascular supply and perfusion. On MRI with contrast, meningiomas and their dural tail/attachment will enhance, which reflects dural infiltration and/or reactive vascularity. Calcifications may appear as low signal intensity or areas void of vascular flow (2). On T1 weighted images, meningiomas appear isointense or hypointense and have signal variability on T2 weighted images. The use of diffusion-weighted imaging has been shown to aid in predicting the histological grade of meningiomas (3). Treatment: Depending on the tumor size and involvement of adjacent structures, planum sphenoidale meningiomas may be removed using approaches such as endonasal transsphenoidal resection. Early decompression of the optic canal and orbiotomy are critical for total resection with excellent outcomes (5). ​​​​ References: Ohba, S., Abe, M., Hasegawa, M., & Hirose, Y. (2016). Intraparenchymal Meningioma: Clinical, Radiologic, and Histologic Review. World neurosurgery, 92, 23–30. doi:10.1016/j.wneu.2016.04.098 Saloner D, Uzelac A, Hetts S, Martin A, Dillon W. Modern meningioma imaging techniques. J Neurooncol. 2010;99(3):333-340. doi:10.1007/s11060-010-0367-6 Ranabhat K, Bishokarma S, Agrawal P, et al. Role of MR Morphology and Diffusion-Weighted Imaging in the Evaluation of Meningiomas: Radio-Pathologic Correlation. JNMA; Journal of the Nepal Medical Association. 2019 Jan-Feb;57(215):37-44. https://europepmc.org/article/med/31080244 Finn JE, Mount LA. Meningiomas of the Tuberculum Sellae and Planum Sphenoidale: A Review of 83 Cases. Arch Ophthalmol. 1974;92(1):23–27. doi:10.1001/archopht.1974.01010010027007 Mortazavi MM, Brito da Silva H, Ferreira M Jr, Barber JK, Pridgeon JS, Sekhar LN. Planum Sphenoidale and Tuberculum Sellae Meningiomas: Operative Nuances of a Modern Surgical Technique with Outcome and Proposal of a New Classification System. World Neurosurg. 2016;86:270-286. doi:10.1016/j.wneu.2015.09.043 Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

40F with headache • Xray of the Week Figure 1. What is the important finding on these images. Figure 2. CT and MRI of cavernous venous malformation. Arterial venous malformation in the left posterior periventricular region with draining veins extending to the internal cerebral veins. A. Axial non contrast CT showing subtle density in left frontal lobe (red arrow). B. Axial T1WI showing cavernous venous malformation (green arrow). C. Axial T1WI with contrast showing cavernous venous malformation with no significant enhancement (green arrow). D. Axial FLAIR showing cavernous venous malformation (green arrow). E. coronal GRE showing cavernous venous malformation with peripheral hemosiderin ring (green arrow). F. Axial GRE showing cavernous venous malformation with peripheral hemosiderin ring (green arrow). Introduction: Cavernous venous malformations (CVM; or cavernomas, cavernous hemangiomas) are clusters of abnormal hyalinized capillaries most commonly located supratentorially and can be found incidentally or present with focal neurological deficits, headaches, and most often seizures (1). CVMs have an incidence of 0.4%-0.8% in the general population (2). They can be seen in adults or children and are either familial (multiple CVMs) or sporadic (usually a single CVM) (1). According to the ISSVA classification of vascular anomalies, these CVMs have been termed slow flow venous malformations. Rupture causing hemorrhage can occur with an average annual rate of 0.7%-1.1% (2), although less common compared to arteriovenous malformations due to their low pressure and flow (1). Discussion: CVMs are difficult to diagnose on cerebral angiography due to their low flow profile and lack of arteriovenous shunting (3). CT has higher sensitivity and shows hyperdense lesions without contrast (Figure 1A), although they can be difficult to visualize since they do not enhance. MRI is more sensitive and specific for detecting CVMs, and is the imaging modality of choice. On T2w and T1w-MR, a rim of hypointensity may be seen (Figure 1D). Using the Zabramski classification, CVMs can be grouped into four types based on appearance on MRI (5). Susceptibility-weighted MR imaging can also be very useful since it can recognize deoxyhemoglobin and hemosiderin deposits which are characteristically associated with CVMs. Blood breakdown products may appear different depending on the MR sequence and the age of the products. Gradient-echo (GRE) MRI offers optimal detection of CVMs, especially if missed by conventional spin echo sequences (4, 6) and can appear as a blooming pattern (Figure 1E). Treatment: Diffusion tensor (DT) imaging (Figure 1F) may be used intraoperatively along with fMRI to better visualize the CVM. DT tractography allows the surgeon to visualize white matter tracts which may cross through or near the hemosiderin rim of the CVM (1,7). Generally, symptomatic CVMs or ones that are in sensitive areas undergo microsurgical resection. If surgical risk is high, stereotactic radiosurgery may be done to prevent progression of CVMs (1). Follow-up MRIs are recommended due to high risk of re-bleeding of CVM remnants (1). ​​​​ References: Mouchtouris N, Chalouhi N, Chitale A, et al. Management of cerebral cavernous malformations: from diagnosis to treatment. ScientificWorldJournal. 2015;2015:808314. doi:10.1155/2015/808314 Ene C, Kaul A, Kim L. Natural history of cerebral cavernous malformations. Handb Clin Neurol. 2017;143:227-232. doi:10.1016/B978-0-444-63640-9.00021-7 Wang, K. Y., Idowu, O. R., & Lin, D. (2017). Radiology and imaging for cavernous malformations. In Handbook of Clinical Neurology (Vol. 143, pp. 249-266). (Handbook of Clinical Neurology; Vol. 143). Elsevier B.V.. doi:10.1016/B978-0-444-63640-9.00024-2 Lehnhardt FG, von Smekal U, Rückriem B, et al. Value of gradient-echo magnetic resonance imaging in the diagnosis of familial cerebral cavernous malformation. Archives of Neurology. 2005 Apr;62(4):653-658. doi:10.1001/archneur.62.4.653 Zabramski JM, Wascher TM, Spetzler RF, et al. The natural history of familial cavernous malformations: results of an ongoing study. J Neurosurg. 1994;80(3):422-432. doi:10.3171/jns.1994.80.3.0422 Campbell PG, Jabbour P, Yadla S, Awad IA. Emerging clinical imaging techniques for cerebral cavernous malformations: a systematic review. Neurosurg Focus. 2010;29(3):E6. doi:10.3171/2010.5.FOCUS10120 Cauley KA, Andrews T, Gonyea JV, Filippi CG. Magnetic resonance diffusion tensor imaging and tractography of intracranial cavernous malformations: preliminary observations and characterization of the hemosiderin rim. J Neurosurg. 2010;112(4):814-823. doi:10.3171/2009.8.JNS09586 Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

44F Trauma and Knee Pain • Xray of the Week Figure 1. What is the important finding on this xray and CT scan. Figure 2. Lateral x-ray and sagittal CT demonstrating a tibial plateau fracture (red arrows) with a fat fluid level (yellow arrows). There is also a fibular neck fracture (green arrows). Introduction: Tibial plateau fractures include a multitude of intraarticular fractures that can be associated with a variety of injuries such as comminution, ligament or meniscal injury, and articular depression (1). They are often associated with motor vehicle accidents or falls. Tibial plateau fractures occur in 10.3 per 100,000 people annually (2). Men younger than 50 had a higher incidence compared to women, with the highest age frequency being between 40 and 60 in both men and women (2). The most common type of tibial plateau fracture is a split-depression unicondylar fracture (AO classification type 41B3) which can be lateral, medial or involving the tibial spines and one of the plateaus. The Schatzker classification system is used for prognosis, management, and pre-operative planning (3), although, some patterns of injury may not fit into this system (4). Other systems include the Luo, Hohl, and AO classifications. Discussion: CT and radiographs are essential imaging modalities to assess tibial plateau fractures (5, 7). Radiographs are useful in detection but may underestimate the fractures in as many as 43% of cases, whereas CT allows a more accurate depiction and enables more precise surgical planning (6). Since this is an intra-articular fracture, plain radiographs may show lipohemarthrosis (Fig. 2) in the joint space, even with subtle fractures (8). It is important to differentiate lipohemarthrosis with simple hemearthrosis which can also occur with tibial plateau fractures (10). MR imaging is useful to depict the internal anatomy of the knee as well as evaluating meniscal and ligamentous injuries associated with the fractures (1). While CT and MR may determine articular depression equally well, MR can demonstrate greater amounts of comminution than CT (1) and is more suitable for diagnosing cartilage lesions (3). Treatment: Using the Schatzker classification, tibial plateau fractures may be managed non-operatively if they are nondisplaced (type I), while multiple indications exist for internal fixation including, but not limited to, open fractures, compartment syndrome, and an articular step off of more than 3 mm (8,9). ​ ​​​​ References: Barrow BA, Fajman WA, Parker LM, Albert MJ, Drvaric DM, Hudson TM. Tibial plateau fractures: evaluation with MR imaging. Radiographics. 1994;14(3):553-559. doi:10.1148/radiographics.14.3.8066271 Elsoe R, Larsen P, Nielsen NP, Swenne J, Rasmussen S, Ostgaard SE. Population-Based Epidemiology of Tibial Plateau Fractures. Orthopedics. 2015;38(9):e780-e786. doi:10.3928/01477447-20150902-55 Markhardt BK, Gross JM, Monu JU. Schatzker classification of tibial plateau fractures: use of CT and MR imaging improves assessment. Radiographics. 2009;29(2):585-597. doi:10.1148/rg.292085078 Molenaars RJ, Mellema JJ, Doornberg JN, Kloen P. Tibial Plateau Fracture Characteristics: Computed Tomography Mapping of Lateral, Medial, and Bicondylar Fractures. J Bone Joint Surg Am. 2015;97(18):1512-1520. doi:10.2106/JBJS.N.00866 Mellema JJ, Doornberg JN, Molenaars RJ, Ring D, Kloen P; Traumaplatform Study Collaborative & Science of Variation Group. Tibial Plateau Fracture Characteristics: Reliability and Diagnostic Accuracy [published correction appears in J Orthop Trauma. 2016 Nov;30(11):e376]. J Orthop Trauma. 2016;30(5):e144-e151. doi:10.1097/BOT.0000000000000511 Wicky, S., Blaser, P., Blanc, C. et al. Comparison between standard radiography and spiral CT with 3D reconstruction in the evaluation, classification and management of tibial plateau fractures. Eur Radiol 10, 1227–1232 (2000). doi:10.1007/s003300000326 Rafii M, Firooznia H, Golimbu C, Bonamo J. Computed tomography of tibial plateau fractures. AJR Am J Roentgenol. 1984;142(6):1181-1186. doi:10.2214/ajr.142.6.1181 Mthethwa J, Chikate A. A review of the management of tibial plateau fractures. Musculoskelet Surg. 2018;102(2):119-127. doi:10.1007/s12306-017-0514-8 Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968--1975. Clin Orthop Relat Res. Jan-Feb 1979;(138):94-104. https://pubmed.ncbi.nlm.nih.gov/445923/ Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Gunshot wound right groin 2 weeks ago. Pulsatile thrill • Xray of the Week Figure 1. What is the important finding on this CT scan and Doppler. Figure 2: A: pseudoaneurysm (red arrow) B: right external iliac artery (green arrow), right external iliac vein (yellow arrow) Note there is contrast in it which is abnormal, left external iliac artery (white arrow), left external iliac vein (blue arrow) Note there is no contrast in it which is normal. C: pseudoaneurysm (red arrow) D: long axis doppler US of right femoral artery (green arrow) and femoral vein (yellow arrow). Note there is abnormal arterial flow in the vein and the flow direction is reversed. E: short axis doppler US of right femoral artery (green arrow) and femoral vein (yellow arrow). Note there is abnormal arterial flow in the vein and there is a fistula visualized between the artery and vein. Introduction: An arteriovenous fistula (AVF) is an abnormal connection between an artery and a vein, which ultimately bypasses the capillary bed allowing blood to go directly into the venous system. Traumatic AVFs can be easy to miss, and up to 70% of patients are given a delayed diagnosis (1). AVFs need to be treated due to potential late complications including pseudoaneurysm (Figs. 1,2), high output heart failure, or AVF rupture resulting in hemorrhage (1). Patients can present with a thrill, bruit, or pulsatile hematoma, but also can be completely asymptomatic (1). Discussion: AVFs can be from an iatrogenic or traumatic source and can also be congenital. In our case, the patient had a gunshot wound to the right groin and presented with a pulsatile thrill. Gold standard for diagnosing AVFs is a CT angiography (CTA), although digital subtraction angiography (DSA) can accurately diagnose them but are less common (1, 2). Duplex and color Doppler sonography are also very useful imaging modalities. In our case, CTA showed contrast in the right external iliac vein (Fig. 2B, yellow arrow) during the arterial phase compared to the normal left side which demonstrates no contrast (Fig. 2B, blue arrow). Further supporting the diagnosis of the AVF is abnormal doppler flow in the femoral artery and vein (Fig. 2D, E). Our case showed communication between the superficial femoral artery and superficial femoral vein at the level of a 1.2 cm pseudoaneurysm. This indicates that there is a post-traumatic AV fistula in the right superficial femoral artery and superficial femoral vein in the proximal to mid-thigh. Treatment: No gold standard for treatment exist regarding repair of traumatic AVFs. In stable patients, AVFs can be treated with endovascular procedures via embolization or stenting (3, 4) to prevent progression of or subsequent complications. Other methods include primary repair of venous and arterial injuries with ligation (1). ​​​​ References: Shaban Y, Elkbuli A, McKenney M, Boneva D. Traumatic femoral arteriovenous fistula following gunshot injury: Case report and review of literature. Ann Med Surg (Lond). 2020;55:223-226. Published 2020 May 30. doi:10.1016/j.amsu.2020.05.016 Chen JK, Johnson PT, Fishman EK. Diagnosis of clinically unsuspected posttraumatic arteriovenous fistulas of the pelvis using CT angiography. AJR Am J Roentgenol. 2007;188(3):W269-W273. doi:10.2214/AJR.05.1230 Rogel-Rodríguez JF, Zaragoza-Salas T, Díaz-Castillo L, Noriega-Salas L, Rogel-Rodríguez J, Rodríguez-Martínez JC. Fístula arteriovenosa femoral postraumática, tratamiento endovascular [Post-traumatic femoral arteriovenous fistula, endovascular treatment]. Cir Cir. 2017;85(2):158-163. doi:10.1016/j.circir.2015.10.010 Liao JL, Wang SK, Dalsing MC, Motaganahalli RL. Endovascular Treatment of a Persistent Traumatic Deep Femoral Arteriovenous Fistula After Gunshot Injury. Vasc Endovascular Surg. 2020;54(5):441-444. doi:10.1177/1538574420918970​ Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

93 F with trauma from a fall. Neck pain • Xray of the Week Figure 1. What is the important finding on this CT scan. Figure 2. CT scan of Type 2 dens fracture. Red arrow is pointing to the fracture line at the base of the dens. Figure 3. Anderson and D’Alonzo dens fracture classification system. Diagram by Neal Joshi. Type I: Avulsion fracture of the tip of the dens, usually stable. Type II: Fracture of the base of the dens, usually unstable. Type III: Fracture involving the body of C2, usually stable. Introduction: The odontoid process, otherwise known as the dens, is a bony projection from C2 (axis). The most commonly utilized classification system for fracture of the odontoid process is the Anderson and D’Alonzo system, which identifies three types of fractures (1) (Fig. 3). C2 fractures can be classified into Odontoid and Hangman’s and most common C2 fractures are the type II odontoid fractures. These can pose issues due to a greater than 50% rate of non-union. These fractures occur during hyperextention and hyperflexion injuries to the cervical spine (falls, motor vehicle accidents). Type II odontoid fractures are most common and can occur at any age but mostly in the elderly due to increase risk of falls and decreased bone mineral density. Discussion: A type I odontoid fracture is described as an avulsion fracture of the tip of the dens. A type II fracture is one that occurs at the base of the dens and is considered unstable due to high rates of non-union. Type III fractures involve the body of C2 and may even involve the facets (Fig. 2). For odontoid fractures, radiographs can be very useful, but a negative result does not exclude a fracture. Therefore, if there is clinical suspicion a CT scan should be obtained (Fig. 1) (3). Non-contrast MRI is useful for viewing ligamentous structures which may be injured. In non-displaced type II odontoid fractures for example, the transverse ligament needs to be intact for certain surgical procedures and would require an MRI for evaluation (4). Complications of odontoid fractures include malunion, non-union, and pseudoarthrosis. Type II fractures are unstable and have a higher rate of nonunion mainly due to the lower surface area of the fractured bone compared to type III fractures. Radiological parameters such as displacement and angulation are important and can determine surgical planning of type II odontoid fractures. Using CT, it was determined that diagnostic classification of displacements and angulation had good observer reliability using review systems and tools in image processing software (5). Figure 4. Fluoroscopic guided placement of an odontoid screw. Treatment: For treatment of type I and III odontoid fractures, external fixation via a rigid cervical collar may be sufficient. For type II fractures, surgical fixation is usually required if there is greater than 4-5 mm of displacement due to high risk for non-union (3) (Fig. 4). ​​​​ References: Korres DS, Chytas DG, Markatos KN, Efstathopoulos NE, Nikolaou VS. The "challenging" fractures of the odontoid process: a review of the classification schemes. Eur J Orthop Surg Traumatol. 2017;27(4):469-475. doi:10.1007/s00590-016-1895-3 Montemurro N, Perrini P, Mangini V, Galli M, Papini A. The Y-shaped trabecular bone structure in the odontoid process of the axis: a CT scan study in 54 healthy subjects and biomechanical considerations [published online ahead of print, 2019 Feb 1]. J Neurosurg Spine. 2019;1-8. doi:10.3171/2018.9.SPINE18396 Chutkan NB, King AG, Harris MB. Odontoid Fractures: Evaluation and Management. J Am Acad Orthop Surg. 1997;5(4):199-204. doi:10.5435/00124635-199707000-00003 Löhrer L, Raschke MJ, Thiesen D, et al. Current concepts in the treatment of Anderson Type II odontoid fractures in the elderly in Germany, Austria and Switzerland. Injury. 2012;43(4):462-469. doi:10.1016/j.injury.2011.09.025 Karamian BA, Liu N, Ajiboye RM, Cheng I, Hu SS, Wood KB. Reliability of radiological measurements of type 2 odontoid fracture. Spine J. 2019;19(8):1324-1330. doi:10.1016/j.spinee.2019.04.020 Neal Joshi is a medical student and aspiring diagnostic radiologist at Rowan University School of Osteopathic Medicine in New Jersey. Prior to medical school, he did research with mouse models for Parkinson’s disease and L-DOPA induced dyskinesias. He also did an internship at Kessler Institute for Rehabilitation in a stroke lab analyzing MR images in ischemic stroke patients with hemispatial neglect. During his time at Rowan, he did research with animal models for traumatic brain injury with an emphasis on electrophysiology of neurons. He graduated from William Paterson University where he completed his studies in biology and biopsychology. Apart from medical school, Neal loves to read, skateboard, go on hikes, and spend time with his friends. Update July 2022: Dr. Joshi is a Radiology Resident at Thomas Jefferson University in Philadelphia. All posts by Neal Joshi Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who Dr. Rice has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD