Scout Film Research Articles

The radiological primary survey: A systematic approach and guide to reading torso computed tomography images in trauma for surgeons

Background Trauma is a disease where time is of the essence. In many lower middle-income countries, definitive management and planning for trauma patients are often delayed after working hours because of either a lack of technicians to perform computed tomography (CT) scans or a lack of radiologists to interpret them. These lacunae can be bridged if more and more surgeons become confident in interpreting trauma CT images. Method In this narrative review, written in a ‘how to do it’ manner, we describe a way of doing a structured and quick ‘radiological primary survey’ of the torso CT, which we believe will help quickly identify major injuries systematically, thereby avoiding delays in management and forming a care plan. The method has been developed by a team of trauma surgeons and radiologists and stems from the DRS ABCDE technique used in interpreting trauma chest X-rays. Result The DRS ABCDE extrapolated to the trauma torso CT includes the following steps- Details, WRAP (W-windowing, R-Region, A-Axis, P-Phase), S- the Scout film, Airway, Breathing, Circulation, Disability and Extras. Conclusion The review will enable resident trainees and trauma care professionals to interpret trauma CTs using a structured approach.

Duplication of the small intestine manifested by obstruction of the gastrointestinal tract – case report

We present the case report of a 24-day-old infant admitted to the Department of Paediatric Surgery in order to treat suspected obstruction of the gastrointestinal tract. For two days prior, the patient had experienced gas and stool retention. On the day of admission, vomiting occurred with gastric contents, later followed by faecal. Ultrasound and scout film of the abdomen were performed, showing radiological features of obstruction of the gastrointestinal tract. The newborn was urgently referred for surgery. The procedure was performed under general anaesthesia. Intraoperatively, at the level of the ileum, 5 cm before the cecum, obstruction of the gastrointestinal tract was found in the form of a lesion resembling Meckel’s diverticulum. Resection of the lesion was performed and end-to-end ileoileal anastomosis was formed. The resected lesion was sent for histopathological examination, which revealed a cystic duplication of the gastrointestinal tract.

Distal Femoral Valgus Resection Angle in Conventional Total Knee Arthroplasty - a CT Scanogram Study.

In conventional total knee arthroplasty (TKA), the distal femur valgus resection angle (DFVA) is decided either by measuring the specific resection angle for each patient on preoperative anteroposterior hip-knee-ankle (HKA) weight-bearing radiograph or using a fixed resection angle of five to seven degrees, when such facilities are not available. This study aims to measure the DVFA in TKA patients using preoperative HKA non-weight-bearing computerized tomography (CT) scanogram scout films and determine its relation with preoperative coronal plane lower-limb deformities. In this retrospective radiological study, various measurements were performed on bilateral, preoperative hip-knee-ankle CT scanograms of 73 knee osteoarthritis patients who had presented for total knee replacement surgery using a standard protocol. The angle between the femoral anatomical axis and femoral mechanical axis was measured as the femoral mechanical anatomical angle (FMAA), which corresponds to the surgical DFVA. The angle between the femoral and tibial mechanical axes was measured as mechanical femorotibial angle (MFTA). The correlation between FMAA and MFTA was studied. The mean FMAA for the study group was 6.45° (range 3° to 11°, SD 1.17°). The MFTA for the study group ranged from 24° varus to 14° valgus. The alignment was valgus in 14.4% (n=21), varus in 84.2% (n=123), and "0 degrees" in 1.3% (n=2). With valgus coronal alignment taken as positive and varus as negative, the Pearson's correlation coefficient for MFTA with FMAA was r = -0.5183 (p<0.001), indicating that valgus knees tended to have a smaller FMA angle and varus knees tended to have a larger FMA angle. In the non-availability of individualized measurements, in primary TKA, we recommend setting DFVA as five degrees for valgus deformities, six degrees for mild/moderate varus deformities (MFTA <15°) and seven degrees for severe varus deformities (MFTA > 15°).

S1690 A Slow Gut Can Hold up Recovery for Cholecystectomy-Induced Bile Leak

Introduction: Bile leak (BL) can occur in up to 0.5% of open cholecystectomies (CCY) and up to 2.7% of laparoscopic CCY. Strasberg types A and D post-CCY BL can be treated with endoscopic retrograde cholangiopancreatography (ERCP) with excellent success rates > 90%. ERCP interventions can decrease the pressure gradient between the bile duct and duodenum and facilitate transpapillary flow of bile. Case Description/Methods: An 81-year-old woman with dementia, recurrent deep vein thrombosis and coronary artery disease presented to an outside hospital with severe abdominal pain and was diagnosed with acute cholecystitis. CCY was delayed by 6 days because she was on ticagrelor and rivaroxaban. Intraoperatively, a gangrenous perforated gallbladder was found, and a surgical drain (SD) was left in-situ. Post CCY she had persistent output from her SD and was transferred to our center for ERCP evaluation of suspected BL. On initial ERCP we found a high-grade Strasberg type A BL from the cystic duct (Figure A). Her major papilla was entirely located within a large duodenal diverticulum. Due to difficulty identifying safe cutting margins within the diverticulum, biliary sphincterotomy (Bsc) was not performed, and a 7 Fr plastic biliary stent was placed which resulted in good flow of bile into the duodenum. Her SD output decreased, and she was discharged the next day. Unfortunately, she was re-admitted to another hospital 3 days later with bile leakage around her SD, vomiting and constipation. An upper gastrointestinal (GI) series excluded a gastric outlet obstruction (Figure B). She was transferred back to our center for ERCP. The scout film showed that oral contrast that was ingested 3 days prior was still present within the proximal jejunum (Figure C). The biliary stent was patent and in good position, but a persistent high-grade BL was seen. Bsc was performed, and an 8mm by 6 cm fully covered self-expanding metal stent (FCSEMS) was placed. The patient was started on an aggressive bowel regimen with resolution of ileus. The SD output ceased, and the SD was removed 3 days later. Unfortunately, patient passed away in hospice before her follow-up ERCP from other causes. Discussion: Despite successful diversion of bile to the duodenum via a biliary stent, small bowel ileus can increase the pressure gradient across the major papilla, resulting in a persistent BL. More aggressive ERCP interventions using FCSEMS, along with aggressive medical treatment of ileus, allowed the BL to heal expeditiously.Figure 1.: A: High-grade cystic duct bile leak on initial ERCP evaluation. B: Contrast flowing from stomach to duodenum in upper gastrointestinal series. The plastic biliary stent is in-situ. C: the oral contrast ingested approximately 3 days prior is still visible within the proximal jejunum on ERCP scout film.

S2217 A Rare Case of Synchronous Double Volvulus of the Sigmoid Colon and Cecum

Introduction: Colonic volvulus is one of the leading causes of large bowel obstruction. Synchronous cecal and sigmoid volvulus is a rare presentation. Cecal volvulus and sigmoid volvulus have traditionally been thought of as separate clinical presentations with distinct clinical features, radiological findings, and treatment modalities. We focus on the classical radiological findings, uncharacteristic presentations, and definitive treatment to prevent recurrence, morbidity, and mortality. Case Description/Methods: A 67-year-old female with a past medical history of severe chronic constipation secondary to stercoral colitis presents to the emergency department complaining of abdominal pain for 5 days. Pain is diffuse, and associated with nausea and vomiting. The last colonoscopy performed 4 years ago, was normal. The patient was in immense pain and was not able to provide further information. On presentation, the patient was afebrile, BP 127/52, HR 73, RR 16 breaths/min. The abdomen was distended, and peritoneal sounds were auscultated in all quadrants but were worse in lower quadrants bilaterally. X-ray of the abdomen showed pneumoperitoneum and dilated bowel related to stercoral colitis. Subsequent CT abdomen showed small volume ascites, hollow perforated viscus, markedly distended cecum with peri-cecal inflammatory changes, and significant wall thickening with inflammation in the sigmoid colon secondary to concurrent cecal and sigmoid volvulus. The patient immediately underwent exploratory laparotomy, ileocecectomy with primary anastomosis, sigmoidectomy with primary anastomosis, and abdominal washout (Figure). Discussion: When evaluating acute abdomen, we propose consideration of synchronous large bowel volvulus is a rare and easily missed etiology of large bowel obstruction due to challenging radiological presentation. Even with detailed cross-sectional imaging like CT scan, it is possible to miss coexisting cecal volvulus due to massively enlarged sigmoid volvulus causing mass effect. The preferred treatment is total or subtotal colectomy with or without anastomosis on a case-to-case basis. This approach provides the advantage of avoiding the risk of recurrence and histopathological analysis to rule out underlying malignancy. Commonly, only one type of large bowel volvulus is found radiologically, it is advisable to pay attention to the possibility of coexisting cecal volvulus and a definitive diagnosis being made intraoperatively.Figure 1.: A. Chest X-ray showing gas under diaphragm; B. Volvulous with dilated caecum and Sigmoid colon on Abdominal X-ray; C. Scout film of the CT scan abdomen; D. Twisted Caecum with dilated sigmoid colon on axial film.

The “Eagle Scout Film”: David Lynch as Auteur and Genre Filmmaker

Knowing David Lynch’s background as an Eagle Scout, this article explores that many of Lynch’s films and their protagonists, particularly Jeffrey Beaumont (Kyle MacLachlan) in Blue Velvet (1986), embody Eagle Scout-like heroes and serve as genre-like “Eagle Scout films.” These films and their protagonists have similarities with the film noir and western genres and their detective/cowboy heroes through their dealings with ethics, morality, and justice in sadistic worlds. In his genre-hybrid films, Lynch acts as an auteur in using recurring thematic preoccupations/stylistic tendencies, while exemplifying hostile environments offset by a central protagonist with an Eagle Scout-like set of morals.

Comparison of Kidney-Ureter-Bladder Radiography with Computed Tomography Scout Film for the Diagnosis of Renal Calculi Taking Axial Computed Tomography as Gold Standard

Background: Nephrolithiasis is a widespread disease with an incidence of 17-13 in North American, 5-9% in Europe, and 1-5% in the Asian continent. Plain abdominal radiography is used to visualize renal stones, but the cysteine stones are often poorly visible, uric acid and mixed stones are not visible at all. The second diagnostic tool for the diagnosis of renal calculus is computed tomography. The CT scout film is often overlooked and did not use for the diagnostic purpose.&#x0D; Objective: To compare Kidney-ureter-bladder radiography with computed tomography scout film for the diagnosis of renal calculi taking axial computed tomography as a gold standard.&#x0D; Materials and Methods: It was a cross-sectional analytical study design conducted on 57 patients presenting with acute flank pain in Faisal Hospital Faisalabad. Patients having ages between 18-60 were included in the study. Pregnant patients and patients with lndinavir therapy were excluded from the study.&#x0D; Results: The sensitivity recorded for CT scout film was 66.7% and for the plain abdominal radiography was 80.7%. The calculus carrying Hounse field unit less than 200 HU were not visualized on both the modalities x-ray and plain abdominal radiography. However, the calculus greater than 5mm in size has a sensitivity of 73% on CT scout film.&#x0D; Conclusion: The sensitivity recorded for CT scout film was 66.7% and for the plain abdominal radiography was 80.7%. The calculus carrying Hounse field unit less than 200 HU were not visualized on both the modalities x-ray and plain abdominal radiography. However, the calculus greater than 5mm in size has a sensitivity of 73% on CT scout film.

Ultra-Low-Dose CT: An Effective Follow-Up Imaging Modality for Ureterolithiasis.

Background and Purpose: Classically, abdominal X-ray (KUB), ultrasound, or a combination of both have been routinely used for ureteral stone surveillance after initial diagnosis. More recently, ultra-low-dose CT (ULD CT) has emerged as a CT technique that reduces radiation dose while maintaining high sensitivity and specificity for urinary stone detection. We aim to evaluate our initial experience with ULD CT for patients with ureterolithiasis, measuring real-world radiation doses and stone detection performance. Methods: We reviewed all ULD CT scans performed at the Veterans Affairs Palo Alto Health Care System between 2016 and 2018. We included patients with ureteral stones and calculated the mean effective radiation dose per scan. We determined stone location and size, if the stone was visible on the associated KUB or CT scout film, and if hydronephrosis was present. We performed logistic regression to identify variables associated with visibility on KUB or CT scout film and hydronephrosis. Results: One hundred eighteen ULD scans were reviewed, of which 50 detected ureteral stones. The mean effective radiation dose was 1.04 ± 0.41 mSv. Of the ULD CTs that detected ureterolithiasis, 38% lacked visibility on KUB/CT scout film and had no associated hydronephrosis, suggesting that they would be missed with a combination of KUB and ultrasound. Larger stones (odds ratio [OR]: 1.40, 95% confidence interval [CI]: 1.08, 1.96 for every 1 mm increase in stone size) were more likely to be detected by KUB/CT scout film or ultrasound, while stones in the distal ureter (OR: 0.18, 95% CI: 0.03, 0.81) were more likely to be missed by KUB/CT scout film or hydronephrosis. Conclusions: Based on our institutions' initial experience, ULD CT detects small and distal ureteral stones that would likely be missed by KUB or ultrasound, while maintaining a low effective radiation dose. An ULD CT protocol should be considered when reimaging for ureteral stones is necessary.

A RARE CASE OF CHEMOTHERAPY-INDUCED PHRENIC NEUROPATHY

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Chemotherapy induced peripheral neuropathy is a well described sequela of several chemotherapeutic agents, which can lead to permanent symptoms and disability in up to 40% of cancer survivors1. Large sensory nerve fibers are most commonly affected; however, motor neuropathy can also develop. Up to 20 to 40% of patients receiving platinum compounds have been reported to experience sensory neurotoxicity, however motor neuropathy is uncommon. Furthermore, motor impairment of the phrenic nerve has rarely been encountered with only four prior case reports being found in the literature2,3,4,5. Only one possible case of platinum associated phrenic neuropathy has been described4. CASE PRESENTATION: A 34 year old male with a metastatic right testicular cancer presented with a three month history of progressive dyspnea on exertion. He had undergone right orchiectomy & had received 4 cycles of chemotherapy with bleomycin, cisplatin and etoposide. Symptoms were first noted during the final cycle of chemotherapy, which continued to progress over the next two months. Physical exam was notable for clear lungs on auscultation with no evidence of diaphragmatic paradox. Pulmonary function tests showed a restrictive pattern, with low maximal inspiratory and expiratory pressures (Figure 1). Repeat CT showed bibasilar atelectasis with low lung volumes on scout film when compared to prior chest x-ray (Figure 2). Fluoroscopic sniff evaluation demonstrated evidence of right greater than left diaphragmatic weakness, and phrenic nerve EMG, while within normal limits, was notable for asymmetric right side predominant nerve conduction discrepancies consistent with possible fascicular phrenic neuropathy. Constellation of findings was most concerning for drug induced phrenic neuropathy leading to diaphragmatic weakness. DISCUSSION: Chemotherapy induced phrenic motor neuropathy leading to diaphragmatic weakness or paralysis is a rarely described phenomenon. Of the four prior case reports, two were associated with vincristine, which is more associated with motor neuropathies2,3. Only one these case reports described a phrenic neuropathy associated with a regimen that included a platinum based agent4. However, this case also involved radiation therapy, which has been associated with phrenic neuropathy in prior case reports. Here we describe a clear case of platinum associated phrenic neuropathy leading to symptomatic diaphragmatic weakness. CONCLUSIONS: Platinum based chemotherapy is a possible cause of phrenic neuropathy leading to diaphragmatic impairment. Reference #1: Park SB, Goldstein D, Krishnan AV, Lin CSY, Friedlander ML, Cassidy J, Koltzenburg M, Kiernan MC. Chemotherapy-induced peripheral neurotoxicity: A critical analysis. Ca Cancer J Clin. 2013;63: 419-437 Reference #2: Stevens WW, Sporn PHS. Bilateral diaphragm weakness after chemotherapy for lymphoma. Am J Respir Crit Care Med. 2014;189(7):12 Reference #3: Gilliland P, Holguin M. Phrenic nerve paralysis due to vincristine. Leuk Lymphoma. 2007;48(12): 2452-2453 DISCLOSURES: No relevant relationships by Vivek Iyer, source=Web Response No relevant relationships by Mark Norton, source=Web Response

Anatomic Factors Affecting Size of Suboccipital Decompression

Abstract INTRODUCTION Emergent suboccipital decompressions are not uncommon procedures for the management of cerebellar infarcts and hemorrhages with mass effect. While anatomic landmarks, such as the transverse sinus and foramen magnum, provide clear boundaries to the decompression, there are a multitude of patient-specific anatomic factors that complicate positioning, and make obtaining an adequate decompression challenging. METHODS We reviewed a consecutive series of patients undergoing emergent suboccipital decompressions. Patients in whom a unilateral decompression was performed were excluded from the study. A total of 43 patients met the inclusion criteria, and were further reviewed. The primary outcome was to determine what anatomic factors predicted maximal width and cranial-caudal extent of SOC bone flap. Head CTs, including scout film radiographs, and chest XRs in the pre- and perioperative period were reviewed to measure specific anatomic features. RESULTS The average patient age was 55 (19-85). 34% of patients were female. A bivariate analysis showed that AP diameter correlated to inion-to-foramen magnum distance (P = .001, r2 = 0.501), shoulder width (P = .001, r2 = 0.509), and soft tissue at C1 measured from posterior arch on CT (P = .004, r2 = 0.444). The angle measured from a plumb line through the CT scout radiograph and a line connecting the inion to the spinous process of C2 also correlated to AP diameter (P = .046, r2 = 0.309). The width of decompression also correlated to the cranial-caudal height (P &lt; .001, r2 = 0.522). A linear regression model demonstrated that cranial-caudal height was predicted (F (16,22) = 2.654, P = .017, r2 = 0.659) by age, maximum SOC width, and BMI (ß = -0.421, P = .031, 95% CI = (-1.067, -0.058)). CONCLUSION We demonstrate that a number of anatomic factors affect the ability to achieve optimal SOC size. While these factors are not modifiable, awareness of these factors may help guide positioning and operative planning to achieve maximum cerebellar decompression and help improve patient functional outcomes after emergent suboccipital decompression.

Computed tomography artifacts mimicking type II odontoid fractures: Report of two cases and review of the literature

IntroductionComputed tomography (CT) has proved highly reliable for cervical spine trauma screening. Nevertheless, rare instances of equivocal imaging findings may lead to misdiagnosis and wrongful management. The role of CT artifacts in this setting has been overlooked. We report 2 cases in which CT-generated artifacts mimicked type II odontoid fractures and nearly misled clinical management. Case reports and literature reviewBoth patients suffered low energy falls and underwent cervical spine CT that disclosed an apparent dislocated type II odontoid fracture. Upon close inspection and review of the initial CT, the artifactual nature of the supposed fractures was exposed as motion artifact, avoiding unneeded surgery. In one of the cases, beam hardening artifact contributed to the false diagnosis. A review of the literature on false-positives in spinal trauma due to CT-generated artifacts was conducted, returning 14 reported cases, all of which generated by motion artifacts. To the best of our knowledge, this is the first report of beam hardening artifact contributing to such complication. ConclusionWith this report, type II odontoid fracture becomes the most common type of artifactual false-positive. The most frequent culprit is motion artifact, but beam hardening artifacts may also play a role. Anatomical factors such as proximity of C2 to the oropharynx and large range of motion of the occipito-atlanto-axial articulation complex might contribute to susceptibility for contamination by motion artifact. CT sagittal reconstructions more easily disclose odontoid fractures, but are also more prone to contamination by artifacts. In order to mitigate these errors, we stress the importance of clinical correlation and critical analysis of the axial images, noticing any blurring or doubling of the bony contours, accompanied by distortion of the adjacent soft tissues, particularly the pharyngeal air column. The CT localizer scout film can also be helpful when in doubt, as well as pursuing repeat scans or alternative imaging methods.

Case 4: Chronic Dysphagia and Weight Loss in a 3-year-old Boy

1. Sarah Mancone, MD* 2. Neelima Tummala, MD* 3. Thomas Pranikoff, MD† 4. Drew P. Plonk, MD* 1. *Department of Otolaryngology and 2. †Department of Pediatric Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC A 3-year-old boy presents to the emergency department with a 1-year history of dysphagia. Per his father, the boy has developed “strange eating habits” where he will place both juice and food into his mouth, swallow the liquid component, and spit out the solid components. Other associated symptoms include spitting up of saliva and progressive weight loss. There is no known history of throat pain, breathing problems, choking episodes, or witnessed foreign body ingestion. The boy has been previously seen by multiple pediatric providers, who attributed his spitting up, decreased oral intake, and weight loss to severe reflux, leading to repeated trials of antacid therapy without improvement in symptoms. Physical examination findings are normal except for the patient appearing malnourished and small for his age. ### Differential Diagnosis The differential diagnosis of a child presenting with gastrointestinal (GI) complaints such as dysphagia, recurrent emesis or spitting up, and weight loss is broad and includes gastroesophageal reflux disease, mechanical obstruction, migraine headaches, and food allergy, among other etiologies. A cause more commonly encountered in the acute setting but possible in the chronic setting is esophageal foreign body (EFB). ### Actual Diagnosis For this patient, the decision was made to proceed with an upper GI radiologic study, and a scout film revealed the presence of a radiopaque EFB that had the typical, circular shape of a coin but an unusual moth-eaten appearance (Fig 1). With this finding, a diagnosis of a chronic EFB after unwitnessed foreign body ingestion was made. Figure 1. Scout film demonstrating a foreign body in the esophagus. ### The Condition Pediatric EFBs …

801 - The efficacy of CT scan scout film in determining the urinary stones biochemical composition

801 - The efficacy of CT scan scout film in determining the urinary stones biochemical composition

Abstract TP480: Standardizing Inpatient Stroke Alert Processes Yields Faster Treatment Times in Inpatient Strokes

Background: In-hospital strokes account for 6.5%-15% of all strokes. Efficiently managing inpatient stroke alerts is a resource-intensive process involving multidisciplinary teams. Standardized emergency department (ED) stroke protocols have been shown to decrease time from stroke alert (SA) activation to neuroimaging and treatment. At our institution, stroke patients arriving to the ED were evaluated and treated faster than inpatient (IP) strokes, highlighting the need for an improved IP SA process to meet work flow benchmarks established by the American Stroke Association. Purpose: Standardizing the IP SA process will decrease time to CT imaging and neurological evaluation, reducing SA activation to treatment times for IP strokes. Methods: A revised in-hospital SA protocol was implemented 8/2016 to prioritize early neurology notification and CT imaging. A total of 332 inpatient SA cases from 1/2013-6/2018 were analyzed for: SA activation to neurology contact, SA activation to CT image scout film time, SA activation to thrombolytic (tPA) administration and/or groin puncture time in cases where a mechanical thrombectomy was performed. Results: Analysis showed significant improvements to all of the outcome measures: 35% improvement in IP SA activation to CT imaging start time (N= 167 prior to protocol revision; N=165 after protocol revision), 36% improvement in SA activation to neurology contact time, 59% improvement in SA to tPA administration time (N=7 prior to protocol revision; N=11 after protocol revision), and a 10% improvement in SA to groin puncture time for thrombectomy cases (N=6 cases prior to protocol revision; N=6 after protocol revision). A 36% increase in IP tPA administrations might be attributed to rapid consideration of eligibility within the treatment window. Conclusions: Standardizing IP SA processes to remove inefficiencies optimizes work flow across all phases of evaluation and leads to faster treatment times and increased treatment rates. These findings may serve as the basis for large-scale multicenter studies to further validate effective protocols’ impact on patient outcomes.

Diagnostic Accuracy of Computed Tomography Scout Film and Chest X-ray for Detection of Rib Fractures in Patients with Chest Trauma: A Cross-sectional Study.

Background: Rib fractures are a major source of morbidity in patients with chest trauma. Computed tomography (CT) scout film is a low-dose image that is obtained prior to a complete chest CT study for all patients undergoing a CT scan. In this study, we evaluated the diagnostic performance of CT scout film vis-à-vis that of chest X-ray for detection of rib fractures using chest CT scan as the reference standard.Methods: A cross-sectional study was performed at the radiology department of Aga Khan University Hospital (Karachi, Pakistan) from October 1, 2013 to September 31, 2014. Patients who underwent CT chest for evaluation of thoracic trauma were included in the study. Sensitivity and specificity of chest X-ray and CT scout film were calculated.Results: A total of 207 patients were included in the study (193 were male). Penetrating and blunt thoracic injuries affected 104 (50.2%) and 103 (49.8%) patients respectively. On CT chest, 75 (36.2%) patients had evidence of rib fractures. Sensitivity and specificity of CT scout film for detection of rib fractures were 56% and 87.9%, while those of chest X-ray were 61.3% and 98.5% respectively. The overall accuracy of CT scout film and chest X-ray for detection of rib fractures were 76.3% and 85% respectively.Conclusion: Diagnostic performance of CT scout film for detection of rib fractures was comparable to that of the plain chest radiograph. CT scout film does not provide any additional information or advantage over a plain chest radiograph. In patients with severe thoracic trauma, CT chest remains the modality of choice for accurate delineation of rib fractures and associated internal injuries.

Femoral malalignment after gamma nail insertion in the lateral decubitus position.

Introduction: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position.Methods: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides.Results: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019).Discussion: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus −valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position.

Voiding Cystourethrography

The voiding cystourethrogram (VCUG) is a fluoroscopic examination commonly used in pediatrics to assess the presence of vesicoureteral reflux (VUR) disease and the structure and function of the bladder and urethra. Along with hydronephrosis and febrile urinary tract infections, the indications for VCUG are vast. Protocols set in place and modern techniques have helped reduce radiation exposure during VCUG to 1.7 to 5.2 mrad. Proper patient preparation and sterile technique during catheter placement are of the upmost importance. The bladder is filled with contrast to the patient’s capacity, followed by the patient voiding. A scout film (anteroposterior [AP]) along with views of early filling (AP), bladder capacity (AP and oblique), voiding (AP and oblique), and postvoid (AP) are obtained. VUR is diagnosed, and its grading system is determined by the VCUG study. Cyclic VCUG, PIC cystography, and radionucleotide VCUG are alternative techniques in diagnosing VUR. Neurogenic bladder, along with its associated pathologies, can be easily characterized by the VCUG examination, as can cloacal and urogenital sinuses via the contrasted study. Bladder ruptures, bladder masses, urachal anomalies, functional disorders of the bladder neck, and a host of urethral pathologies (most notably posterior urethral valves) can be diagnosed by VCUG. This review contains 62 highly rendered figures, 6 tables, and 9 references Key words: voiding cystourethrography, fluoroscopy, radiology, imaging, pediatric, urology, vesicoureteral reflux

Rectal gas volume: Defining cut-offs for screening for evacuation disorders in patients with constipation.

Diagnosis of rectal evacuation disorders (RED) is currently based on anorectal manometry (ARM) and evacuation tests in specialized laboratories; we recently showed higher rectal gas volume (RGV) and maximum rectal gas transaxial area (MRGTA) measured on abdominal and pelvic computed tomography (CT) in patients with documented RED.The aim of this study was to obtain cut-off values of RGV, MRGTA, and rectal area on scout film (RASF) to differentiate constipated patients with RED from those without RED, based on ARM, balloon expulsion test (BET), and colon transit test. We identified 118 constipated patients (65 with RED) with prior record of CT. Using standard CT software, we used a variable region of interest (ROI) program to measure RGV, MRTGA, and RASF, as previously described. We constructed receiver operating characteristics curves based on different values, and we estimated AUC, specificity, and positive predictive value (PPV) to detect RED in patients with constipation. Receiver operating characteristics of the models to predict RED showed AUC 0.751 for RGV and 0.737 for MRGTA (both P<.001), and 0.623 for RASF (P=.029). At specificity of 90%, RGV of 30mL had a PPV 77.3%, MRGTA of 10cm2 had a PPV 75.0%, and RFAS of 9cm2 had a PPV of 68.8% for identifying constipated patients with RED. Rectal gas measurements on abdominal imaging may indicate RED in patients with constipation. At ~90% specificity for RED, RGV of 20 or 30mL or MRGTA of 10cm2 on CT has PPV ~75%, and RASF of >9cm2 has PPV of ~69%.

Rectal Gas Volume Measured by Computerized Tomography Identifies Evacuation Disorders in Patients With Constipation.

Approximately one third of patients who present to gastroenterology care with constipation have rectal evacuation disorders. We aimed to compare rectal gas volume, measured by computerized tomography (CT), in constipated patients with and without rectal evacuation disorders. In a retrospective study, we collected data from 1553 patients with constipation, evaluated over 20 years. We analyzed data from 141 patients evaluated by anorectal manometry, balloon expulsion tests, and colon transit tests, collecting records of abdominal and pelvic CT examinations. Patients were classified into 3 subgroups: those with rectal evacuation disorders, slow-transit constipation, or normal-transit constipation. Two observers used standard CT software to identify variable regions of interest on each cross-sectional CT image that contained rectum and measured areas of gas in each slice; they then summated entire volumes of rectal gas. For the 3 groups, we compared rectal gas volume, maximal rectal gas transaxial area (measured by CT), and area of rectal gas (vertical) on the 2-dimensional abdominal film (scout) using the Kruskal-Wallis test. The intraclass correlation coefficient between 2 observers' measurements of rectal gas volume was 0.99 (P < .001). There were overall group differences in rectal gas volume and the maximal rectal gas transaxial area (both P < .001). The median rectal gas volume was higher in patients with rectal evacuation disorders (13.84 cm3) than in patients with slow-transit (2.51 cm3) or normal-transit constipation (1.33 cm3, both P < .05). Similarly, the area of rectal gas, which correlated with the maximal rectal gas transaxial area (Spearman correlation coefficient, 0.7; P< .001), showed overall 3-group differences (P= .033), with greater areas of rectal gas on the abdominal scout film in patients with rectal evacuation disorders than in those with normal-transit constipation. In an analysis of patients with constipation, we found rectal gas volume, determined by abdominal CT imaging, to be greater in patients with than without rectal evacuation disorders.

Cervical spine immobilization in the elderly population.

Immobilization of the cervical spine is a cornerstone of spinal injury management. In the context of suspected cervical spine injury, patients are immobilized in a 'neutral position' based on the head and trunk resting on a flat surface. It is hypothesized that the increased thoracic kyphosis and loss of cervical lordosis seen in elderly patients may require alternative cervical immobilization, compared with the 'neutral position'. To investigate this, an audit of pan-scan CT performed on consecutive major trauma patients aged over 65 years was carried out over a 6-month period. Utilizing the pan-CT's localizing scout film, a novel measurement, the 'chin-brow horizontal' angle was independently measured by a senior spine surgeon (RJM) and a neurosurgeon (PJR) with the gantry used as a horizontal zero- degree reference. The benefit of the 'chin-brow horizontal' angle in the trauma setting is it can be assessed from the bedside whilst the patient is immobilized against a flat surface. During the 6-month study period, 58 patients were identified (30 male, 28 female), with an average age of 77.6 years (minimum 65, maximum 97). Results showed that 'chin-brow horizontal' angles varied widely, between +15.8 degrees in flexion to -30.5 degrees in extension (mean -12.4 degrees in extension, standard deviation 9.31 degrees. The interobserver correlation was 0.997 (95% CI: 0.995-0.998). These findings suggest that, due to degenerative changes commonly seen in elderly patients, the routine use of the 'neutral position' adopted for cervical spine immobilization may not be appropriate in this population. We suggest that consideration be taken in cervical spine immobilization, with patients assessed on an individual basis including the fracture morphology, to minimize the risk of fracture displacement and worsened neurological deficit.