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18 year old male. Trauma due to punching a punching bag • Xray of the Week Figure 1. What is the important finding on this xray. Figure 2. Frontal, lateral, and oblique radiographs showing hamate body fracture (red arrows) due to the patient punching a punching bag. Introduction: Hamate fractures represent around 2-4% of all carpal fractures (1). Fractures involving the hamate bone can be divided into two broad categories. Type I is a hook of the hamate fracture and type II involves the body (Figs. 1,2). Type I can be specified under three subtypes depending if they involve the base, the waist, or is an avulsion of the tip (2). The type II hamate fracture can be either 2a which is a coronal fracture, dorsal oblique, or splitting, or 2b which is transverse. Mechanisms of injury may be related to sports (especially tennis, baseball and golf) which fracture the hook, and body fractures are most commonly from punch injuries as seen in this case (2). Discussion: Although hamate fractures can be identified on hand radiographs, sometimes they may be difficult to diagnose. A missed diagnosis in the ED often delays orthopedic involvement which can result in long term functional disabilities and can destabilize the fourth and fifth carpometacarpal joints (3). Cecava and colleagues identified six potential radiographic signs of a hamate fracture: 1) distal dorsal hamate avulsion fragment, 2) noncongruent metacarpal alignment, 3) fourth/fifth CMC joint obscuration, 4) disruption or obscuration of hamate hook ring, 5) hamate double density sign, and 6) ulnar and dorsal soft tissue hand swelling (3). They also correlated these findings to their respective findings on CT. If these radiographic findings and clinical findings indicate a hamate fracture, a CT is the preferred imaging modality to thoroughly classify these fractures (3). A study showed that radiographs of hamate fractures were around 72% sensitive with 89% specificity. A high resolution CT showed to have 100% sensitivity and 94% specificity (4). Treatment: With acute nondisplaced hook fractures, immobilization with an ulnar gutter cast for 6 weeks may be sufficient. Displaced fractures usually require open reduction and internal fixation or excision of the bony fragment. Nonunion fractures require pinning with bone grafting. Acute nondisplaced and displaced fractures of the body of the hamate have similar treatments as hook fractures (1-4).​ ​​​​ References: Goliver JA, Adamow JS, Goliver J. Hamate body and capitate fracture in punch injury. Am J Emerg Med. 2014 Oct;32(10):1303.e1-2.. Epub 2014 Apr 3. PMID: 24792935. doi:10.1016/j.ajem.2014.03.050 Mouzopoulos G, Vlachos C, Karantzalis L, Vlachos K. Fractures of hamate: a clinical overview. Musculoskelet Surg. 2019 Apr;103(1):15-21. Epub 2018 May 29. PMID: 29845407. doi:10.1007/s12306-018-0543-y Cecava ND, Finn MF, Mansfield LT. Subtle radiographic signs of hamate body fracture: a diagnosis not to miss in the emergency department. Emerg Radiol. 2017 Dec;24(6):689-695. Epub 2017 Jun 14. PMID: 28616787. doi:10.1007/s10140-017-1523-5 Andresen R, Radmer S, Sparmann M, Bogusch G, Banzer D. Imaging of hamate bone fractures in conventional X-rays and high-resolution computed tomography. An in vitro study. Invest Radiol. 1999 Jan;34(1):46-50. PMID: 9888053. doi:10.1097/00004424-199901000-00007 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 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

1 month male old with vomiting • Xray of the Week Figure 1. What is the important finding on this ultrasound of a 1 month old male? Figure 2: Ultrasound of pylorus. A. Target sign on the short axis view with the thickness measuring 0.60 cm (N<0.30 cm). B. The longitudinal plane shows an elongated pylorus measuring 2.23 cm (N<1.60 cm) with thickened pyloric muscle, also known as the cervix sign. The pyloric mucosa protrudes into the gastric antrum which is the antral nipple sign (red arrows) Introduction: Hypertrophic pyloric stenosis (HPS) is seen in infants causing gastric outlet obstruction from a thickened pylorus muscle. The incidence is around 2-5 in 1000 live births every year. Infants from 2-6 weeks old present characteristically as projectile non-bilious vomiting which can be severe enough to cause hypochloremic, hypokalemic metabolic alkalosis and dehydration (1, 2). Risk factors include but are not limited to, smoking during pregnancy, preterm delivery, first-born infants, and exposure to macrolides such as erythromycin (3). Discussion: The gold standard imaging technique for diagnosing HPS is ultrasound with high specificity and sensitivity. Sonographic signs of HPS include (4): -Target/Donut sign- Echogenic mucosa surrounding thickened pyloric hypoechoic muscle (Figs. 1A, 2A). -Cervix sign- showing thickened pylorus on longitudinal view (Figs.1B, 2B) -Antral nipple sign- pyloric mucosa protruding into the gastric antrum (Fig. 2B) Sonographic measurements of the pyloric wall >0.30 cm and pyloric length of >1.5 cm (Fig. 1,2) indicate HPS (1, 2). Some authors even suggest that the numerical values are less important compared to the morphology of the antropyloric canal in real-time on ultrasound (2). There also may be a lack of gastric emptying which can be seen on upper GI series if ultrasound is non-diagnostic. Endoscopy can also be a diagnostic tool but is rarely used due to its invasive and cost-ineffective nature (1). Treatment: Once the infant is rehydrated, surgical pyloromyotomy is curative with excellent outcomes (5). ​​​​ References: Hernanz-Schulman M. Infantile hypertrophic pyloric stenosis. Radiology. 2003;227(2):319-331. doi:10.1148/radiol.2272011329 Niedzielski J, Kobielski A, Sokal J, Krakós M. Accuracy of sonographic criteria in the decision for surgical treatment in infantile hypertrophic pyloric stenosis. Arch Med Sci. 2011;7(3):508-511. doi:10.5114/aoms.2011.23419 Galea R, Said E. Infantile Hypertrophic Pyloric Stenosis: An Epidemiological Review. Neonatal Netw. 2018;37(4):197-204. doi:10.1891/0730-0832.37.4.197 Indiran V, Selvaraj V. The cervix sign and other sonographic signs of hypertrophic pyloric stenosis. Abdom Radiol (NY). 2016;41(10):2085-2086. doi:10.1007/s00261-016-0809-5 Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pediatr Surg. 2007;16(1):27-33. doi:10.1053/j.sempedsurg.2006.10.004 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

19 yo M who fell • Xray of the Week Figure 1. Describe the wrist injury. Figure 2. A. Plain radiograph of the wrist demonstrating subtle fracture of the waist of the scaphoid (yellow arrow) and nondisplaced fracture of the scaphoid tubercle (red arrow). B. Coronal CT scan of the wrist demonstrating the minimally displaced fracture of the scaphoid tubercle (red arrow). C. Axial CT scan of the wrist demonstrating the minimally displaced fracture of the scaphoid tubercle (red arrow). D. Coronal CT scan of the wrist demonstrating the minimally displaced fracture of the waist of the scaphoid. (yellow arrow). Figure 3. Mayo Clinic Scaphoid Fracture Classification: Scaphoid bone fractures are classified by anatomic position. The location of the fracture is significant because the decreasing blood flow distal to proximal can lead to complications in healing (such as AVN). Diagram by Nirali Dave. Figure 4. Volar view of scaphoid blood supply. Superficial Palmer Branch of Radial Artery enters the scaphoid bone distally around the tibial tuberosity and provides 20-30% of the blood supply. Diagram by Nirali Dave. Figure 5. Dorsal view of scaphoid blood supply. Dorsal Carpal Branch of Radial Artery enters scaphoid bone through the dorsal ridge and provides 70-80% of the blood supply with thinner branches proximally. Diagram by Nirali Dave. Discussion: Scaphoid fractures have been well-reported as a challenge to diagnose and treat. Patients with scaphoid fractures usually present with severe wrist pain, swelling, and decreased range of motion following high-energy trauma. Anatomical snuffbox tenderness, pain on axial compression of the thumb, and scaphoid tubercle tenderness have extremely high sensitivity for scaphoid fractures, but have variable specificity [1,2]. The initial imaging modality used to diagnose scaphoid fractures is plain radiography, however x-rays can miss up to 30% of fractures in the acute setting. If clinical suspicion of a scaphoid fracture is high but no fracture is seen on x-ray, the appropriate next step is CT scan [1-3]. The Mayo classification system for scaphoid fractures is organized according to anatomic location in the scaphoid bone: proximal third, middle third (waist), distal third (Fig. 3). Of these, proximal third fractures account for 10% of all scaphoid fractures, waist fractures account for 70%, and distal third fractures account for 20% [4]. Distal tubercle fractures are rare, accounting for only 5% of all scaphoid fractures and are visualized on x-rays as avulsed small radiovolar fragments of the distal tip [4,5]. The distal third of the scaphoid bone receives its blood supply from radial artery branches (Figs. 4-5); therefore, healing of a distal tubercle fracture usually proceeds without complication. Since the remainder of the scaphoid bone depends on the blood supply from the distal third of the scaphoid, vascular disruption due to a scaphoid waist fracture may result in complications such as nonunion, avascular necrosis, and chronic radiocarpal osteoarthritis [6]. Because there is excellent vascularity found in the distal third of the scaphoid bone, patients with scaphoid tubercle fractures are normally treated with immobilization in a thumb spica short cast, with full recovery taking about 4-6 weeks. Conversely, scaphoid fractures of the proximal third and waist can have more protracted healing timelines. If imaging indicates a non-displaced scaphoid waist fracture, minimally invasive percutaneous screw fixation has achieved promising results. More unstable scaphoid fractures often require open operative treatment that can still result in complications such as delayed or nonunion [6,7]. ​​​​ References: 1. Puopolo SM, Rettig ME. Management of acute scaphoid fractures. Bulletin of the NYU Hospital for Joint Diseases. 2003;61(3,4). http://hjdbulletin.org/files/archive/pdfs/681.pdf 2. Platon A, Poletti P-A, Aaken J, et al. Occult fractures of the scaphoid: the role of ultrasonography in the emergency department. Skeletal Radiology. 2011;40(7):869-875. doi:10.1007/s00256-010-1086-y 3. Kaewlai R, Avery LL, Asrani AV, et al. Multidetector CT of carpal injuries: anatomy, fractures, and fracture-dislocations. Radiographics : a review publication of the Radiological Society of North America, Inc. 2008;28(6):1771-1784. doi:10.1148/rg.286085511 4. Gupta V, Rijal L, Jawed A. Managing scaphoid fractures. How we do it? Journal of Clinical Orthopaedics and Trauma. 2013;4(1):3-10. doi:10.1016/j.jcot.2013.01.009 5. Prosser AJ, Brenkel IJ, Irvine GB. Articular Fractures of the Distal Scaphoid. Journal of Hand Surgery (British and European Volume). 1988;13(1):87-91. doi:10.1016/0266-7681(88)90061-7 6. Clementson M, Björkman A, Thomsen NOB. Acute scaphoid fractures : Guidelines for diagnosis and treatment. Efort Open Reviews. 2020;5(2):96-103. doi:10.1302/2058-5241.5.190025 7. Rhemrev S, Ootes D, Beeres F, Meylaerts S, Schipper I. Current methods of diagnosis and treatment of scaphoid fractures. International Journal of Emergency Medicine. 2011;4(1):1-8. doi:10.1186/1865-1380-4-4 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 2022: Dr. Dave is a Radiology Resident 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. Formerly the 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the Cardiac Device • Xray of the Week Figure 1. Name the cardiac device. Figure 2. Plain radiograph demonstrating the MitraClip Cardiac Device (green arrows). Figure 3. CT scan demonstrating the MitraClip Cardiac Device (green arrows). Figure 4. Video demonstrating trans-septal placement technique for MitraClp from Abbott. Discussion: Mitral regurgitation (MR) is the most common form of severe valve disease in developed countries. Approved for use in 2013, the MitraClip system provides an alternate means for Mitral Valve (MV) repair in patients deemed too high risk for surgery. The system works by creating an edge to edge tissue bridge between the anterior and posterior leaflets of the MV via a clip inserted via catheter transeptally. Radiographically the device will be seen as 1 or 2 small metallic devices over the mitral valve area (Figs. 1-3). Preprocedural imaging is used to diagnose the extent and severity of the MR, and 3D - TEE is typically the imaging modality of choice as it allows for visualization and quantitative analysis of the complex geometry of the MV (Fig.4). Periprocedural imaging again also relies heavily on 3D – TEE as valve pathophysiology determines the ideal puncture site for access. Fluoroscopy and TEE are usually the modalities of choice for real time visualization during MitraClip placement. When 2D/3D TEE are used in conjunction there is an associated 28% reduction in procedural times. After placement of the system, postprocedural imaging should be utilized to assess for any residual MR, which has been shown to be a predictor of long term survival. ​​​​ References: 1. Weerakkody Y. Mitraclip device | Radiology Reference Article | Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/mitraclip-device?lang=us. Accessed March 31, 2020. 2. Imaging in MV Interventions: MitraClip and Beyond... American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2018/08/06/13/25/imaging-in-mv-interventions. Accessed March 31, 2020. 3. Sherif MA, Paranskaya L, Yuecel S, et al. MitraClip step by step; how to simplify the procedure. Neth Heart J. 2017;25(2):125-130. doi:10.1007/s12471-016-0930-7 4. Tamburino C, Ussia GP, Maisano F, et al. Percutaneous mitral valve repair with the MitraClip system: acute results from a real world setting. Eur Heart J. 2010;31(11):1382-1389. doi:10.1093/eurheartj/ehq051 5. Chrissoheris MP, Halapas A, Papadopoulos K, Spargias K. Transcatheter MitraClip implantation facilitated by transthoracic echocardiography. J Echocardiogr. 2018;16(2):91-92. doi:10.1007/s12574-017-0358-0 6. Ramlawi B, Skiles J, Myers D, Ali O, Viens C. Transcatheter mitral repair: MitraClip technique. Ann Cardiothorac Surg. 2018;7(6):824-826. doi:10.21037/acs.2018.10.14 Related posts: Transcatheter Aortic Valve Replacement (TAVR) Transcatheter Mitral Valve Replacement (TMVR) Malposition of Right Atrial Lead of Permanent Pacemaker Implanted Cardiac Loop Recorder Wearable Cardiac Defibrillator Impella Left Ventricular Assist Device Micra Intracardiac Pacemaker Neal Shah went to medical school at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and matched in radiology at Vanderbilt University Medical Center. 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. 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 Cape Radiology Group, and formerly the Chief of Staff at 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Name the Cardiac Device • Xray of the Week Fig. 1. A. Frontal chest xray showing the Amplatzer® Septal Occluder Device over the expected location of the atrial septum (red arrows). Fig. 1. B. Echochardiogram 4 chamber view showing the Amplatzer® Septal Occluder Device (yellow arrows) covering both sides of the atrial septum. Fig. 1. C. CT scan showing the Amplatzer® Septal Occluder Device (green arrows) covering both sides of the atrial septum. The self-expanding distal lobe is seen in the left atrium and the proximal disc is seen in the right atrium. A large pericardial effusion is also present. Fig. 2. Frontal (A) and lateral (B) chest xray in a different patient showing the Amplatzer® Septal Occluder Device over the expected location of the atrial septum (red arrows). Fig. 3. Amplatzer® Septal Occluder device. Fig. 4 Video demonstrating percutaneous placement technique for the Amplatzer® Septal Occluder for ASD closure. Discussion: The Amplatzer Septal Occluder (ASO) is designed for percutaneous closure of atrial septal defect (ASD), the fourth most common congenital cardiac anomaly. ASD closure is indicated within the setting of right cardiac chamber enlargement, prevention of paradoxical embolism, net left to right shunting, and to prevent arrythmias [1]. The device is shaped as a self-expanding double disc composed of a nitinol mesh with polyester fabric (Figs.1-3). The double disc shape allows closure from both sides of the septal defect with one disc being placed alongside the left septal wall within the left atrium, and the other being placed along the right septal wall within the right atrium. This means that only ASD secundum type defects are able to be repaired with this device [2,3]. Despite the improving accuracy of both 2D and 3D echocardiography, fluoroscopy remains the standard for periprocedural imaging [4,5]. After the device has been placed postprocedural imaging is typically conducted via echocardiography to evaluate for device positioning and any residual shunting. As seen in this case, the discs are visible over the interatrial septum on radiographs, ultrasound, and CT scan (Figs.1,2). Closure with this device is a highly successful procedure and offers lower rates of post-procedural complications than seen with open heart surgery and a shorter hospital stay (Fig. 4). The most common complication during placement is device embolization or malposition which occurs in 3.5% of cases. The most frequent long term complication following ASO placement is arrythmias, typically supraventricular tachyarrhythmias [6]. The other potential long term complication is myocardial erosion which may lead to pericardial effusion or tamponade [6]. Mortality rates between the ASO device and surgical groups in studies tend to be similar [6]. References: Holland M. Amplatzer septal occluder | Radiology Case | Radiopaedia.org. Radiopaedia. https://radiopaedia.org/cases/amplatzer-septal-occluder?lang=us. Accessed April 12, 2020. Kim H-H, Yi G-J, Song S-W. Late Migration of Amplatzer Septal Occluder Device to the Descending Thoracic Aorta. Korean J Thorac Cardiovasc Surg. 2017;50(1):47-49. doi:10.5090/kjtcs.2017.50.1.47 Sigakis CJG, Mathai SK, Suby-Long TD, et al. Radiographic Review of Current Therapeutic and Monitoring Devices in the Chest. RadioGraphics. 2018;38(4):1027-1045. doi:10.1148/rg.2018170096 Sigakis CJG, Mathai SK, Suby-Long TD, et al. Radiographic Review of Current Therapeutic and Monitoring Devices in the Chest. RadioGraphics. 2018;38(4):1027-1045. doi:10.1148/rg.2018170096 Ackermann S, Quandt D, Hagenbuch N, et al. Transcatheter Atrial Septal Defect Closure in Children with and without Fluoroscopy: A Comparison. Journal of Interventional Cardiology. doi:https://doi.org/10.1155/2019/6598637 Spence MS, Qureshi SA. Complications of transcatheter closure of atrial septal defects. Heart. 2005;91(12):1512-1514. doi:10.1136/hrt.2004.057562 Related posts: CardioMEMS Device Amulet® Left Atrial Appendage Closure Device Implanted Cardiac Loop Recorder Cardiac Tamponade Following Coronary Artery Rotational Atherectomy Papillary Fibroelastoma of Aortic Valve Micra Intracardiac Pacemaker ​​ Neal Shah went to medical school at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and matched in radiology at Vanderbilt University Medical Center. 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. 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 Cape Radiology Group, and formerly the Chief of Staff at 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Natalie Rice, Vice President of Global Radiology CME, enjoyed an exciting week in the ancient and vibrant city of Jerusalem. Time was spent meeting with representatives at the luxurious 5 star Inbal Jerusalem Hotel, the venue for our upcoming conference - Imaging in Israel - 2023. Natalie had extensive planning meetings with Sigalit Hurvitz making sure every detail of the program would well organized. Even senior members of the Inbal management team, including VP of Operations, Nahum Mazor and General Manager, Rony Timsit were involved in the planning of the upcoming Imaging in Israel 2023 conference. The entire staff at the Inbal looks forward to welcoming Global Radiology CME Faculty and Registrants to Imaging in Israel 2023, June 5-8, 2023 in a city known as the historic and religious nucleus of civilization. The feeling one gets while in the holy city is aptly described on the Inbal Hotel website: "The power of Jerusalem lies in its atmosphere. It’s something unique and sacred – a special feeling in the air. A visit to Jerusalem is an experience that’s filled with magic, each time allowing you to reach out and touch history." Join Global Radiology CME June 5-8, 2023 in Jerusalem for Imaging in Israel 2023 and see for yourself how visiting Israel allows you to tour sites as old as history itself!

48 yo male wrist pain following a MVA with persistent pain for one month • Xray of the Week The patient's hand was on the horn at time of impact and the steering wheel mounted airbag deployed, contributing to the injury. Normal wrist xray. Persistent pain for one month, then had an MRI. Figure 1. Describe the wrist injury. Figure 2. MRI of Hook of hamate fracture. A. Axial T1-weighted image demonstrates the body of the hamate (blue arrow), the hook of hamate (green arrow), and a fracture through the base of the hook of the hamate (yellow arrow). B. Axial fast spin echo proton density image with fat saturation demonstrates the body of the hamate (blue arrow), the hook of hamate (green arrow), and a fracture through the base of the hook of the hamate (yellow arrow). There is also high signal in the distal hamate due to edema C. Coronal STIR image demonstrates high signal in the distal hamate due to edema (red arrow). Discussion: Hamate fractures are rarely encountered carpal bone fractures, comprising approximately 2% of all carpal bone fractures (1,2). Anatomically, the hamate bone is found in the distal carpal row situated at the ulnar aspect of the wrist. It is wedge-shaped and has a bony prominence at the volar aspect regarded as the hook of hamate. Hamate fractures can be broadly divided into two groups according to Milch’s classification: hamate body fractures and hook of hamate fractures (2). Hook of hamate fractures are further subdivided according to their location in the hook: Type 1 fractures are located at the distal hook, type 2 at the middle, and type 3 are located at the base of the hook. Type 3 fractures account for the majority of hook of hamate fractures (6). High impact injuries--when rigid objects strike the hand--as seen in a fall or blunt trauma, can result in hamate fractures. Sporting injuries involving repetitive motions with equipment such as golf clubs, rackets, and baseball bats are also associated with hamate fractures, and are seen most frequently in younger men. Patients can present with pain and tenderness over the hypothenar eminence with limited wrist range of motion (2,3). Initial radiographs obtained at the first visit are often negative due to difficulty capturing the appropriate view of the fractured hamate bone (3,6). If the initial radiographs are negative, patients may continue to experience pain and follow up to get more advanced imaging such as CT or MRI. CT scans have very high sensitivity and specificity for picking up all types of hamate fractures. MRI is the imaging modality of choice for radiographically occult hamate fractures because of its high sensitivity for bone marrow signal irregularities and can display associated ulnar nerve or flexor tendon findings (3,4). In this case, the axial images reveal a linear signal abnormality at the base of the hook (Figs. 1,2), consistent with a type 3 fracture of the hook of the hamate (3-6). Complications of a long-standing fracture without treatment include flexor tendon rupture, nonunion, and chronic post-traumatic osteoarthritis (5). The standard treatment for nondisplaced hook of hamate fractures immobilization via ulnar gutter splint (3-6). Displaced hamate body fractures commonly require open reduction and internal fixation (ORIF). Surgical excision of the hamate hook fragment is used for symptomatic displaced fractures, nonunion, and nondisplaced hook fractures older than 3 months (3-6). In this particular case, after several months of conservative management and persistent non-union, this patient underwent excision of the hook, resulting in alleviation of his pain. ​​​​ References: 1. Cecava ND, Finn MF, Mansfield LT. Subtle radiographic signs of hamate body fracture: a diagnosis not to miss in the emergency department. Emergency Radiology. 2017;24(6):689-695. doi:10.1007/s10140-017-1523-5 2. Arthur J, Jorgensen SA, Towbin AJ, Towbin R. Hook of the hamate fracture. Applied Radiology. 2018;47(2):29-31. Hook of the hamate fracture. https://www.appliedradiology.com/articles/hook-of-the-hamate-fracture 3. O’Shea K, Weiland AJ. Fractures of the Hamate and Pisiform Bones. Hand Clinics. 2012;28(3):287-300. doi:10.1016/j.hcl.2012.05.010 4. Mandegaran R, Gidwani S, Zavareh A. Concomitant hook of hamate fractures in patients with scaphoid fracture: more common than you might think. Skeletal Radiology. 2018;47(4):505-510. doi:10.1007/s00256-017-2814-3 5. Snoap T, Habeck J, Ruiter T. Hamate Fracture. Eplasty. 2015;15:ic28. Hamate Fracture. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462833/ 6. Davis DL. Hook of the Hamate: The Spectrum of Often Missed Pathologic Findings. AJR 2017; 209:1110–1118. doi:10.2214/AJR.17.18043 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. Follow Nirali Dave on Twitter @ndave08 All posts by Nirali Dave Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Cape Radiology Group. Formerly the Chief of Staff at 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

Travelling in Israel is safe and fun, with so many sights to see and a vast array of activities to do. We just returned from a wonderful visit to Tel Aviv putting together the final details for our Imaging in Israel - 2017 conference. It was our third business trip to Israel in the past 12 months. Parade in Tel Aviv June 2015-Photo by Kevin Rice When we were not busy checking out venues or meeting with vendors we found time to enjoy the sight, sounds, and tastes of Tel Aviv. We walked along the seaside promenade, enjoyed lunch at sidewalk cafes, and sipped wine on the beach as we watched the sun set over the glistening Mediterranean. The beaches were packed and people were out walking at all hours of the day and night - that's summer in Tel Aviv! We took the above picture from a parade last June where 200,000 people came to the city from all over Europe and the Mideast to celebrate diversity. The parade traveled right along the beach and in front of the Dan Tel Aviv Hotel where the Imaging in Israel - 2017 conference will be located. Watching the Sunset at Banana Beach in Tel Aviv - Photo by Kevin Rice Some people have asked us if we feel safe in Israel. Our answer is a resounding YES. We live in an age where incidents happen all over the globe. Israel is actually one of the safest countries in the world and the crime rate is far lower in Israel than the US in almost every category.(1) Enjoying the Beach in Tel Aviv - Photo by Kevin Rice Israel is full of security experts; Israeli security techniques and personnel are used as a formidable resource around the world. In fact, there is Israeli security on some of the world's most popular cruise lines. A recent article by CNN described Tel Aviv's Ben Gurion International Airport as one of the safest in the world.(2) A blog post by Becki Enright, a British Press award winning travel writer says "for those of you wondering if Tel Aviv is a safe city to travel in, it absolutely is. I never once felt threatened or vulnerable to issues surrounding the current conflict – don’t believe the hype!"(3) The above is a video of tourists, asked if they were afraid to come to Israel. Some were and some were not. See what they have to say once they got to Israel. Feeding a Kangaroo at Gan Garoo - Photo by Natalie Rice There are so many exciting things to do in Israel. Beyond the major historic sites like Masada and the Old City of Jerusalem, we found a unique experience. We got a taste of Australia, by visiting Gan Garoo - Australian Park in the north of Israel where you can pet kangaroos. The tame kangaroos will even eat directly from your hand! Lunch on the Beach in Tel Aviv - Photo by Nathan Rice Every time we go to Israel we do something new and interesting. We hope you will join us in Tel Aviv in June 2017 for Imaging in Israel. -Natalie and Kevin Rice All posts by Kevin Rice, MD 1. Crime stats - Israel vs USA: http://www.nationmaster.com/country-info/compare/Israel/United-States/Crime 2. CNN: Tel Aviv Airport: http://www.cnn.com/2016/05/28/travel/ben-gurion-worlds-safest-airport-tel-aviv/ 3. Travel Blog: http://www.bordersofadventure.com/exploring-tel-aviv-neighbourhoods-israel-second-largest-city/

by Nishtha Raval, Rend Al-Khalili, MD, and Kevin Rice, MD 63 F with one month history of enlarging right breast with redness and tenderness. What is the diagnosis? • Xray of the Week Figure 1. A) Mammogram MLO view. Focal asymmetries involving most of the anterior and mid right breast with diffuse skin thickening, trabecular coarsening and increased overall density of the right breast. Abnormally enlarged right axillary lymph nodes are also visualized. Figure 2. A. Bone scan shows diffuse uptake in the markedly enlarged right breast secondary to increased blood pool activity and impaired washout. B. Mammogram CC view. Focal asymmetries involving most of the anterior and mid right breast with diffuse skin thickening, trabecular coarsening and increased overall density. Discussion: 63-year-old woman presented to a clinic with a one month history of progressively enlarging right breast with redness and tenderness. Physical examination revealed an enlarged, erythematous, indurated right breast with a peau d’orange appearance. Multiple fixed underlying breast masses were palpated in the upper breast. In addition, there were multiple enlarged right axillary lymph nodes. A mammogram demonstrated focal asymmetries involving most of the anterior and mid right breast with diffuse skin thickening, trabecular coarsening, increased overall density, and enlarged right axillary lymph nodes. Ultrasound guided biopsy yielded invasive ductal carcinoma with lymphatic invasion. Bone scan showed diffuse uptake in the markedly enlarged right breast secondary to increased blood pool activity and impaired washout. Inflammatory breast cancer (IBC) is a rare subtype of breast cancer that accounts for 2%–5% of all breast cancers [1-3]. Both tissue diagnosis of malignancy and clinical evidence of inflammatory disease are required to confirm the diagnosis of IBC [3]. Around 3-6 months and most commonly within 3 months into the disease progression, changes of the skin and development of an underlying mass will be appreciated and are used to validate the diagnosis. The key feature that differentiates IBC from Locally Advanced Breast Cancer (LABC) is the onset of symptoms, as symptoms of non-IBC LABC typically develop over a more protracted period [3]. Skin punch biopsy may be performed but is not required for diagnosis. On examination, edema and erythema span sat least one-third of the breast tissue, and peau d’orange is present in some cases [3]. Once the clinical picture and baseline laboratory tests for tumor markers like cancer antigen 15-3 and CEA confirm the diagnosis, local imaging with mammogram and ultrasound will help guide management as standards of care [1]. Because of the inflamed breast tissue causing added pain during the process of mammography, visualization of the breast tissue and the lesion of concern is often limited, but will demonstrate findings such as microcalcifications, trabecular thickening/coarsening, and diffusely increased breast density [1]. However, if the lesion is not visualized on imaging, this does not preclude the diagnosis of IBC [1]. Ultrasound has a higher rate of detection and greater sensitivity, and will often reveal a solid mass, skin thickening, and/or parenchymal changes as well as accompanying axillary lymph node involvement [1]. PET/CT scan is especially useful for visualizing lymph node metastasis, as well as monitoring treatment response [1]. MRI has taken an increasingly important role in characterizing IBC and separating it from other similarly presenting pathologies, such as acute mastitis [4,5]. Diffuse subcutaneous pre-pectoral edema is one key to diagnosing IBC seen on MRI, as well as skin thickening occupying at least one-third of the breast [5]. Inflammatory breast cancer tends to affect older, non-lactating women whereas mastitis is typically seen in younger women who are lactating [2]. It can often be difficult to clinically differentiate inflammatory breast cancer from mastitis given their similar presentation; however, improvement after a trial of antibiotics suggests mastitis [2]. ​​​​ References: Chow CK. Imaging in inflammatory breast carcinoma. Breast Dis. 2005;22:45-54. doi:10.3233/bd-2006-22106 Dahlbeck SW, Donnelly JF, Theriault RL. Differentiating inflammatory breast cancer from acute mastitis. Am Fam Physician. 1995;52(3):929-934.Papalouka V, Gilbert FJ. Inflammatory breast cancer-importance of breast imaging. Eur J Surg Oncol. 2018;44(8):1135-1138. doi:10.1016/j.ejso.2018.05.008 Menta A, Fouad TM, Lucci A, et al. Inflammatory Breast Cancer: What to Know About This Unique, Aggressive Breast Cancer. Surg Clin North Am. 2018;98(4):787-800. doi:10.1016/j.suc.2018.03.009 Papalouka V, Gilbert FJ. Inflammatory breast cancer-importance of breast imaging. Eur J Surg Oncol. 2018;44(8):1135-1138. doi:10.1016/j.ejso.2018.05.008 Uematsu T. MRI findings of inflammatory breast cancer, locally advanced breast cancer, and acute mastitis: T2-weighted images can increase the specificity of inflammatory breast cancer. Breast Cancer. 2012;19(4):289-294. doi:10.1007/s12282-012-0346-1 Nishtha Raval is a fourth year medical student at Georgetown University School of Medicine with aspirations to become a Diagnostic Radiologist. She completed her undergraduate education at Georgetown and studied Healthcare Management and Policy. She is passionate about leadership and mentorship in Radiology, as well as how we can go about improving health outcomes in our healthcare system through quality improvement. Nishtha has been involved in several campus leadership positions and currently serves on the Medical Student Subcommittee as the Mentorship Program Co-Lead for the American College of Radiology. In her spare time, she enjoys trying new restaurants, painting, and spending time with her family. Dr. Rend Al-Khalili is an Assistant Professor of Radiology at MedStar Georgetown University Hospital, specialized in Breast Imaging. She completed her diagnostic radiology residency training at Rutgers University Hospital and her breast imaging subspeciality training at Columbia University Medical Center. Besides training residents and fellows, she is very passionate about providing educational opportunities for medical students and has won multiple teaching awards in her career. At Georgetown University, she serves as the medical student clerkship course director for breast imaging. Dr. Al-Khalili has strong interest in research and has published in many aspects of breast Imaging with particular focus on education. She is a reviewer for many radiology journals including the Breast Journal, American Journal of Roentgenology (AJR) and Journal of Breast Imaging (JBI) where she also served on the Editorial Board. Dr. Al-Khalili currently serves as the co-chair of the Young Physician Committee of the Society of Breast Imaging as well as the Members-in-Training Education Chair for the DC chapter of the American College of Radiology. Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. Formerly the 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 and , 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

We are pleased to announce that eight of the medical students who were in the Global Radiology CME Future Radiology Resident (#futureradres) mentoring program have matched to impressive Radiology Residencies across the country. Global Radiology CME's Kevin Rice, MD has given these industrious students the opportunity to learn about radiology by writing up interesting cases and publishing them on the Global Radiology CME online teaching file. Always looking for new challenges and opportunities for outreach, in 2020 Dr. Rice began this now very successful program of mentoring medical students interested in radiology residencies. In the inaugural year of his mentoring program all 6 of his medical students successfully matched in top radiology programs including Indiana University, Thomas Jefferson University, Vanderbilt, Amita Health, and Northwestern. The mentoring program continued its success and 8 medical students matched to radiology for the 2022 academic year. This is the list of students and where they matched: Corey Brown - Brigham and Woman's Hospital Deven Champaneri - Medical University of South Carolina Mounica Chidurala - Indiana University Sai Kilaru - Henry Ford Hospital Savan Patel - Geisinger Medical Center Austin Sanu - Northwell Mather Hospital Leslie Shang - University of Kansas Usha Trivedi - UC San Diego Click the links on their names to see their cases. If you are in private practice or academic practice and want to "give back" by mentoring a medical student who aspires to become a radiologist, contact us to get involved in this very successful program. info@globalradcme.com "I just want to say thank you for the opportunity to write for Global Radiology CME! I strongly believe it helped me have a successful match. The programs asked more about how I got involved with writing for you. Also, they were a great talking point during the interviews to showcase my interest in radiology!" Deven Champaneri, Medical Student - Matched to Medical University of South Carolina Radiology Related articles: Dr. Kevin Rice: Semifinalist for 2021 AuntMinnie.com's Most Effective Radiology Educator Figure 1 Features Dr. Kevin Rice Kevin Rice, MD - One of the #HumansOfRadiology

90 yo F with UTI. Diagnosis? • Xray of the Week Figure 1. Non-contrast CT abdomen & pelvis of a 90-year-old female. Figure 2. Figure 1: Non-contrast CT abdomen & pelvis of a 90-year-old female with a UTI demonstrating emphysematous pyelonephritis and a renal stone within the renal pelvis. A. Coronal non-contrast CT of abdomen & pelvis showing gas (green arrow) and renal stone (red) within the renal pelvis. B. Axial non-contrast CT of abdomen & pelvis showing gas (green arrow) and renal stone (red arrow) within the renal pelvis. C. Axial non-contrast CT of abdomen & pelvis showing gas within the bladder (orange arrow). Discussion: Emphysematous pyelonephritis (EPN) is a necrotizing infection that leads to gas formation within the renal parenchyma, collecting system, and/or perinephric areas. It is commonly seen in patients with uncontrolled diabetes, urinary tract obstruction or urinary stones, or immunocompromised state. Female patients have an increased risk of developing EPN due to higher incidence of UTIs caused by Escherichia coli, Klebsiella pneumonia, and Proteus mirabilis [1]. Like pyelonephritis, patients with EPN often present with fever, abdominal or flank pain, and costovertebral angle tenderness. Urinalysis may show pyuria, leukocytosis, nitrites, hematuria, WBC casts; however, imaging is required to confirm the diagnosis [2,3,4]. CT abdomen and pelvis is the gold standard for confirming EPN [5]. The most comprehensive classification system used to categorize EPN is developed by Huang and Tseng (Table 1) and best correlates with management [4]. Classification of Emphysematous Pyelonephritis Class 1: Gas accumulation in the renal pelvis Class 2: Gas accumulation in the renal parenchyma Class 3A: Gas extension into the perinephric space Class 3B: Gas extension into the pararenal space Class 4: Gas in solitary or bilateral kidneys Table 1: Classification of Emphysematous Pyelonephritis. [4] It is likely that the 90-year-old female patient shown in Figure 1 had a complication of EPN due to a UTI and a renal stone causing an obstruction at the renal pelvis. The urinary organisms thrive in an immunocompromised host and lead to a rapid progression from a UTI to EPN [4]. Bacteria within the urinary tract can ferment glucose and albumin and produce H2 and CO2 gas seen in Figure 1 (green and orange arrows) [6]. This case is classified as Class 1 EPN because the gas accumulation is restricted to the renal pelvis and complicated by a renal stone. This can be managed with antibiotics, percutaneous catheter drainage (PCD), fluid, electrolyte, and glucose control (Fig. 4) [4]. Figure 4. The flowchart for management of emphysematous pyelonephritis (EPN) according to the clinicoradiological classification. Asterisk indicates the presence of 2 or more of the following risk factors: thrombocytopenia, acute renal failure, disturbance of consciousness, and shock. KUB indicates kidneys, ureter, and bladder (plain abdominal radiograph); CT, computed tomography; and PCD, percutaneous catheter drainage. From: Emphysematous Pyelonephritis: Clinicoradiological Classification, Management, Prognosis, and Pathogenesis Arch Intern Med. 2000;160(6):797-805. doi:10.1001/archinte.160.6.797 Copyright © 2000 American Medical Association. All rights reserved. Date of download: 7/25/2021 EPN is a life-threatening condition that warrants an immediate treatment. Most common cause of death in EPN is caused by urosepsis and has a mortality rate of 19-75% [7, 8]. In severe cases or patients who do not respond to PCD, treatment with nephrectomy can lead to clinical and radiological improvement (Fig. 4) [4]. ​​​​ References: Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011;107(9):1474-1478. doi:10.1111/j.1464-410X.2010.09660.x Kuo CY, Lin CY, Chen TC, et al. Clinical features and prognostic factors of emphysematous urinary tract infection. J Microbiol Immunol Infect. 2009;42(5):393-400. https://pubmed.ncbi.nlm.nih.gov/20182668/ Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology. 1996;198(2):433-438. doi:10.1148/radiology.198.2.8596845 Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160(6):797-805. doi:10.1001/archinte.160.6.797 Craig WD, Wagner BJ, Travis MD. Pyelonephritis: Radiologic-Pathologic Review. RadioGraphics. 2008; 28:255-276. https://doi.org/10.1148/rg.281075171 Dhingra KR. A Case of Complicated Urinary Tract Infection: Klebsiella pneumoniae Emphysematous Cystitis Presenting as Abdominal Pain in the Emergency Department. West J Emerg Med. 2008;9(3):171-173. https://pubmed.ncbi.nlm.nih.gov/19561737/ Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol. 1991;146(1):148-151. doi:10.1016/s0022-5347(17)37736-4 Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol. 1984;131(2):203-208. doi:10.1016/s0022-5347(17)50309-2 Mounica Chidurala is a medical student at Marian University College of Osteopathic Medicine in Indianapolis, IN. Prior to medical school, she graduated from Oklahoma State University with a Bachelor of Science degree in Chemical Engineering, minor in Chemistry, and an Honors College Degree. She also obtained her Master of Science degree in Chemical Engineering from the University of Oklahoma where she defended her master’s thesis in biofuels and heterogeneous catalysis. She is excited to pursue a career in Diagnostic Radiology with interests in Interventional Radiology or Nuclear Medicine. She is passionate about research and innovation in medicine and hopes to teach/mentor students in the future. Follow Mounica Chidurala on Twitter @mchidurala227 and Linkedin All posts by Mounica Chidurala 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 and Linkedin All posts by Kevin M. Rice, MD

Orbital injury due to rubber bullet. Describe the injury. • Xray of the Week Figure 1. Describe the injury. Figure 2. A. Axial CT showing extensive vitreous hemorrhage of globe (yellow arrows) B. Coronal CT showing orbital blowout fracture affecting the right inferior orbital wall (red arrow) and right medial orbital wall (green arrow) Discussion: Rubber bullets are typically used to disperse demonstrations by inflicting nonlethal injuries [1]. However, they can cause serious injuries as seen in this case. Ophthalmic injuries due to rubber bullets include ruptured globes, blunt force bruising, orbital fractures, complex facial fractures, and brain injuries [2]. The severity of the injury depends on the viscosity and elastic limit of the body area that is targeted [3]. The face and eyes have low elastic limit, so severe penetrating injuries occur with rubber bullets while body areas with high elastic limit such as the limbs and back suffer blunt injuries [3] (Fig. 3). Figure 3. Rubber bullet injury to the left anterior abdominal wall sustained during a riot in Los Angeles. (Snapchat- Kevin Rice. Los Angeles. June 2, 2020.) In this case, there is an orbital blowout fracture affecting the inferior and medial orbital walls and the globe shows extensive vitreous hemorrhage. In blowout fractures, damage occurs to the orbital wall without affecting the orbital rims [4]. CT may show herniation of the inferior rectus muscle or the orbital fat [4]. Orbital CT scans in globe and orbit injuries can show rupture of the globe, fractures of the orbital walls and roof, facial fractures, and optic nerve avulsion [2]. If the presence of a metallic foreign body is definitively ruled out, MRI may also be used [5]. MRI may be helpful in cases where intraorbital hemorrhage is suspected [5]. For globe injuries, ultrasonography may be used to examine lens dislocation, retinal detachment or hemorrhage, and hyphema although it is contraindicated in patients with globe rupture and is less sensitive than CT in detecting foreign objects [6]. The patient in this case has injury to the globe with extensive vitreous hemorrhage which typically appears as hyperattenuation on CT with periorbital soft-tissue swelling [6]. Treatment includes removal of the rubber bullet or any of its fragments [7]. If the globe is penetrated by the projectile or it is directly hit, as in this case, it is rarely salvageable [1]. The majority of blowout fractures are treated conservatively. Surgical intervention is indicated when there is diplopia or enophthalmos that exceeds 2 mm [7,8]. In cases with a large fracture involving at least half of the orbital floor especially when associated with large medial wall fractures, there is high risk for significant enophthalmos when initial edema and hemorrhage resolve, so surgery is also indicated in these cases (8]. Prophylactic antibiotic treatment is also recommended to reduce the risk of infection [4,7]. ​​​​ References: Lavy, T., Asleh, S. Ocular rubber bullet injuries. Eye 17, 821–824 (2003). https://doi.org/10.1038/sj.eye.6700447 Ifantides, C., Deitz, G.A., Christopher, K.L. et al. Less-Lethal Weapons Resulting in Ophthalmic Injuries: A Review and Recent Example of Eye Trauma. Ophthalmol Ther 9, 1–7 (2020). https://doi.org/10.1007/s40123-020-00271-9 Mahajna A, Aboud N, Harbaji I, Agbaria A, Lankovsky Z, Michaelson M, Fisher D, Krausz MM. Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study. Lancet. 2002 May 25;359(9320):1795-800. doi: 10.1016/S0140-6736(02)08708-1 Koenen L, Waseem M. Orbital Floor Fracture. [Updated 2020 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534825/ Lin KY, Ngai P, Echegoyen JC, Tao JP. Imaging in orbital trauma. Saudi J Ophthalmol. 2012;26(4):427-432. doi:10.1016/j.sjopt.2012.08.002 Sung EK, Nadgir RN, Fujita A, Siegel C, Ghafouri RH, Traband A, Sakai O. Injuries of the globe: what can the radiologist offer? Radiographics. 2014 May-Jun;34(3):764-76. doi: 10.1148/rg.343135120 Pinto L, do Canto AM, Filho JV, de Freitas RR. Treatment of a Penetrating Intraorbital Injury by Rubber Projectile. Craniomaxillofacial Trauma & Reconstruction Open. January 2017. doi:10.1055/s-0037-1604033 Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology. 2002;109(7):1207-1213. doi:10.1016/s0161-6420(02)01057-6 Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends. Follow Amara Ahmed on Twitter @Amara_S98 All posts by Amara Ahmed 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