Sameer Raniga
@samrad77
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Radiologist. Trauma and Emergency Radiology. One view is NO view. #radtwitter | #FOAMrad | #radres | #radEd | #radiology | #EmergencyRad
Muscat, Oman
Joined March 2013
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Pinned Tweet
This will be my pinned tweet. Till the end of time.
Let's demyth the contrast induced nephropathy (better contrast associated acute kidney injury).
Thank you
@DGlaucomflecken
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A group of Radiologists avoiding direct patient interaction 😀
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The first CT scanner was created by British engineer Godfrey Hounsfield in 1972.
ER physicians before 1972:
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ER physician sending patients for imaging during my on-call: 😅
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How NOT to miss a compression fracture of the vertebral body on CT?
Look for the following features: 5Ds
1. Dense (sclerotic) # line
2. Depression- wedging
3. Deformity- end plates (depression)
4. Deformity- buckling or cortical step
5. Discontinuity- cortex (corners)
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A picture is worth 1,000 words!
Reference: New Bone Formation in Axial Spondyloarthritis: A Review. Rofo. 2023 Nov 9. English. doi: 10.1055/a-2193-1970. Epub ahead of print. PMID: 37944938.
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Urologists rightly advise that frequently emptying the bladder can save your life from the risk of stones... This is an example...
😅
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Was driving home today when I thought I saw a Spy Balloon, until I realized it was Birdshit on my Windshield 😅
Lesson: One view is NO view.. 🫢
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That one Radiologist in your department who never retires… 😀
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Radiologist and pathologist in tumor board when the others are discussing management plan..
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A beautiful diagram showing spectrum CT findings in Interstitial fibrosing lung disease
Source: unknown (please claim if you know).
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When oncologist is looking for a radiologist to have a quick look at that staging CT with 12 prior CT/MRI
Radiologist me:
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Don't overcall ! Not a fracture.
Oppenheimer ossicles are accessory ossicles associated with the facet joints. Relatively common.
--On-call cases
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Trauma C spine radiograph.
Intercalary bones at C4-5 and C5-6. Dont report it as “fractured osteophytes”.
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Cuboid fracture is one of the commonest missed fractures (up to 3/4th) on radiographs.
1. Cuboid #
2. Normal cuboid for comparison
—my on-call cases
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Here are the key measurements to take when examining a hip radiograph in a patient with suspected femoroacetabular impingement (FAI)
Femoral morphology: Alpha angle
Acetabular morphology: CEA and Tonnis angle
Acetabular coverage: Depth- global
Acetabular coverage: Depth-focal
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Subtle injury not to miss!
Flexor retinacular avulsion injury.
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Absence soft tissue swelling or preservation of air in this triangular portion of the nasal cavity (deep/medial to the nasal bone and lateral to the nasal septum)- has almost 100% negative predictive value for a nasal bone fracture (excludes nasal fracture).
I don’t look at the
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What is this cortical based humeral lesion? Benign or Aggressive or variant?
PS- ignore the enchondroma 😊
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Why do I see bowel gas pattern everywhere on post-call day?
PS: clouds
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Another reminder!
It's not an osteophyte fracture.
Just a discal-annulus calcification.
Cervical osteophyte fractures are extremely rare (they probably don’t exist in isolation). Almost unknown in the absence of rigid spine (AS or DISH) or prevertebral soft tissue swelling. Almost all of them are discal or annulus calcifications. Just ignore.
--on-call wisdom
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How to spot a radiologist in the hospital?
Clue: calm and focused on what they need to do irrespective of chaos of life 😂
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Interesting ! The eyes expression change with the mouth, even if we don’t move the eyes. That is why we have to smile a lot.
Keep smiling always...
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When a radiologist accidentally stumbled upon a stethoscope 😂
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Why do I see bowel gas patterns everywhere? What’s wrong with me? 😅
— from a radiologist’s diary
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Presence soft tissue swelling or loss of normal air in this triangular portion of the nasal cavity (deep/medial to the nasal bone and lateral to the nasal septum)- has almost 100% positive predictive value for a nasal bone fracture.
—on-call wisdom
Absence soft tissue swelling or preservation of air in this triangular portion of the nasal cavity (deep/medial to the nasal bone and lateral to the nasal septum)- has almost 100% negative predictive value for a nasal bone fracture (excludes nasal fracture).
I don’t look at the
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Drop your speciality joke..
Mine is: I have a radiology joke, but it has to be correlated clinically. 😅
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Don’t call it avulsion of anterior SI ligament. Normal in children.
—pelvic trauma pitfalls
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Osteosarcoma: Just a perfect radiology-pathology correlation ❤️
Codman triangle: This term is used to describe a type of periosteal reaction seen in aggressive lesions (osteosarcoma here) in which the periosteum is elevated and a triangle of new bone forms at the margin of a lesion beneath the elevated periosteum.
— Textbook cases from
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Typical bone infarction.: Serpiginous intramedullary sclerosis is a typical feature on radiographs.
—classic cases on-call
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Radiologists versus non-radiologists interpreting imaging studies 😅
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Middleton positioning is used to optimally evaluate rotator cuff (supraspinatus) on ultrasound.
How to judge a correct Middleton position..
Mastero in action! Prof. Martiloni
@WFUMB
#wfumb2023
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Hill-Sachs lesions are best seen on AP shoulder with internal rotation.
— on-call tips
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Normal in children.
Scaphoid ossification.
Don’t call it a fracture.
—on-call pitfalls
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One of the best diagrams and annotated MRI images of the anatomy of the third ventricle and the relationship of different structures in the mid-sagittal plane.
Normal anatomic landmarks in the sagittal plane. Sagittal diagram (a) and T2-weighted MR image (b) show some of the key
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Pseudo-delta sign of subdural hematoma on Non-enhanced CT.
Not venous sinus thrombosis.
—on-call cases
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Me trying to hide that 9 MM thyroid nodule in the body of CT chest report..
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Lisfranc ligament complex: 3 components. Dorsal, interosseous, and planter. Which is the strongest?
Reply in the poll...
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Cervical osteophyte fractures are extremely rare (they probably don’t exist in isolation). Almost unknown in the absence of rigid spine (AS or DISH) or prevertebral soft tissue swelling. Almost all of them are discal or annulus calcifications. Just ignore.
--on-call wisdom
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Pitfall: Don't overcall them venous sinus thrombosis.
Well-defined round/oblong CSF attenuation filling defects are arachnoid granulations.
--on-call cases
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Metatarsal shaft fracture with cortical thickening- suggests stress fracture.
—on-call tips
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Me explaining to radiologists colleagues that IV contrast is safe and can be given even with compromised renal function.. 😅
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Regarding the elderly with non-traumatic subdural hematoma (SDH), timing SDH on imaging as acute/subacute/chronic or acute on chronic is unnecessary. The majority have SDH that is chronic (cSDH).
What to report:
1. Size (on coronal and not axial)
2. Location (convexity,
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Pitfall: Not an avulsion fracture of the lesser trochanter.
Diagnosis: Calcific tendinosis of iliopsoas insertion. HADD.
—on-call misses-mimics and misinterpretation
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How do you protocol and interpret CTA in a patient with suspected Acute Aortic Syndrome (AAS)?
This- “hot-off-the-press”-
@RadioGraphics
article by Murillo et al. reviews the systematic CT search pattern and analysis in a suspected AAS.
1/15
#RGphx
@cookyscan
#tweetorial
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How do we differentiate acute from old osteoporotic vertebral compression fracture (VCF) on a radiograph?
If you don’t see any steps or sclerotic lines, and if you can trace the entire perimeter of a vertebral body on a lateral radiograph (visible and sharp), it is old/remote.
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Numerous ossicles in the ankle or foot can be mistaken for fractures. When in doubt, ask yourself, "Is this a common ossicle versus a rare fracture, or a common fracture versus a rare ossicle?" This approach usually works.
Wikipedia images show normal ossicles of the foot!
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Trauma surgeon looking for a radiologist to review the PAN CT scan 0.2 sec after it’s done !
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Thin, smooth sheet-like dural thickening adjacent to an old craniotomy or burr hole site is normal.
Don’t overcall it bleed or tumor.
—on-call pitfalls
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Answer: True subluxation.
Why?
Specific red flags on radiographs can identify a true subluxation. When these red flags are present, it is important to consider true subluxation rather than pseudo subluxation.
The red flags are as follows:
1. Age: If the patient is over 8
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“Snow-cap mountain sign” of both humeral heads due to AVN (sickle cell disease).
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Neurorad describing findings on a brain MRI scan which I reported on-call as “no acute insult”
😂
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Easily missed injuries: Lisfranc fracture dislocation
Increased C1-M2 distance on an AP foot radiograph- > 3 MM- is a red-flag. Ask for CT or MRI.
I prefer CT in all suspicious cases. MRI only after negative CT.
—on-call wisdom
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This is how ankle effusion/hemarthrosis looks like on radiograph…
A teardrop-shaped or ovoid soft tissue density displacing the anterior fat pad.
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How to differentiate protrusio acetabuli from coxa profunda on radiographs?
Join me tomorrow to learn more...
@docskalski
Join us for next AMS monthly webinar on 27th Jan. It is free to join.
@samrad77
,
@ESSRmsk
,
@intskeletal
#radres
,
@mskradiologyuk
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A Diagnosis radiologist describing his eventful day at work to an interventional radiologist!
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Radiologist attending a “code blue” - cardiac arrest code 😅
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Pedicle destruction- blinking owl eye! Mets
—my today’s case
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Just a great example of bilateral multifocal bone infarction- medullary lesions of sheet-like central lucency surrounded by sclerosis with a serpiginous border. Patient with sickle cell disease..
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CT features of burst fracture:
1. Fracture extends to the posterior cortex
2. Loss of posterior vertebral height
3. Retropulsion of the posterior cortex
4. Comminuted fracture with centrifugal displacement
5. Neural arch- vertical fractures
6. Interpedicular widening
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Classic case!
Sunburst ☀️ periosteal reaction of osteosarcoma!
—my reporting list
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Positive Hawkins sign for comparison: A thin rim of lucency in the subchondral bone plate that runs parallel to the articular surface suggests preserved vascularity of the talus and makes avascular necrosis unlikely.
--Trauma-imaging pearls
The absence of Hawkin's sign (which looks like the crescent of lucency parallel to the talar dome) with increased sclerosis in a patient with talar # suggests avascular necrosis.
--Trauma-imaging pearls
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One view is NO view.
Subchondral insufficiency fracture (SIF)- crescent 🌙 sign - only seen on lateral view.
—on-call cases
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As a radiologist we listen through you- ordering physicians.
Please provide us with a good history and clinical indication for imaging you request..
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Oncologist: Can we discuss just one case?
Me: sure.
The case:
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Os intermetatarseum (accessory ossicle) simulating a fleck sign of Lisfranc injury.
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Pitfall: Normal synchondrosis of inferior pubic ramus. Can be unilateral.
Don’t call it fracture or tumor.
—on-call cases
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Ghost sign: Disappearance of bony contours on T1W images and reappearance after contrast administration. It is described in many reviews as pathognomonic for osteomyelitis in Charcot's foot.
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For C spine trauma evaluation, which out of the following four is the most important line?
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Don’t miss base 5th MT fracture on lateral ankle radiograph!
Follow the Checklist!
—on-call cases
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If you see the entire lateral collateral ligament of knee on a single coronal slice, it’s a sign of anterior tibial translation and complete ACL tear.
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Ghost sign: MRI sign of osteomyelitis.
It was primarily described to confirm osteomyelitis in diabetic neuropathic arthropathy. However, it can be applied anywhere in bones.
In a non-contrast T1-weighted image, it is described as a poorly defined margin of the bones (Ghost)
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