There are bilateral upper lobe predominant alveolar opacities. 2. Bilateral lobar pneumonia. The distribution of the opacities in the upper lobes is characteristic of pneumonia due to Streptococcus pneumoniae (pneumococcus). 3. The lungs are divided into zones to help localize abnormalities: - Upper zone: above the level of the carina - Middle zone: between the carina and inferior pulmonary veins - Lower zone: below the inferior pulmonary veins Knowing the zone helps determine the likely causative organism - S. pneumoniae causes upper lobe pneumonia typically.

1. Emergency Radiology Quiz Cases
Dr Eric Heffernan
St Vincent’s University Hospital

2. Emergency Cases
• Here are twenty-one cases that were referred for
imaging from the Emergency Department in
SVUH
• Have a look at the images on the first slide in
each case
• On the next slide are clinical details and some
questions for you to consider
• The answers are on the third slide for each case,
followed by a slide with the same images labelled

3. Case 1

4. Case 1
• 44 year old man with dyspnoea, cough and
mild pyrexia
1. How would you describe the CXR?
2. What is your diagnosis?
3. What part of the lung is involved and why?
4. What follow-up would you suggest, if any?

5. Case 1 - Answers
1. The PA CXR shows increased airspace opacification in the right
lower zone. The normal silhouette of the right heart border is
obscured. On the lateral view the opacity is wedge-shaped and is
located anteriorly.
2. Lobar pneumonia.
3. Right middle lobe – the consolidation obscures the right heart
border and on the lateral view it outlines the horizontal and
oblique fissures (see next slide). Note also that the horizontal
fissure has been pulled inferiorly, indicating that there is a degree
of collapse as well as consolidation.
4. The patient should have a follow-up CXR after completing their
antibiotic therapy to ensure complete resolution of the
abnormality – occasionally there will be an underlying neoplasm.

6. Right heart border is
obscured, but right
hemidiaphragm
silhouette
is preserved
Right oblique fissure
Horizontal fissure

7. Case 2

8. Case 2
• 64 year old man presented with pleuritic chest
pain one month post coronary artery bypass.
Mild pyrexia and leukocytosis.
1. How would you describe the CXR?
2. What is your diagnosis?
3. What other radiographic abnormality can
potentially be found in this condition?

9. Case 2 - answers
1. PA CXR shows a well-defined opacity at the left lung base
that obliterates the silhouette of the left hemidiaphragm
and curves superiorly at its lateral aspect, i.e. a meniscus
sign indicating a pleural effusion. Sternotomy wires are
demonstrated and the heart is mildly enlarged.
2. Given the recent history of cardiac surgery, Dressler’s
syndrome was diagnosed.
3. Pericardial effusions are common in Dressler’s syndrome
but may not be large enough to be radiographically
apparent – if old chest radiographs are available they may
allow us to detect new diffuse enlargement of the cardiac
shadow due to pericardial effusion.

10. Case 3

11. Case 3
• Query fracture.
1. What is your diagnosis?

12. Case 3
• Have you spotted the abnormality yet?
• If not, try looking again with these clinical
details: fell earlier today and is complaining of
pain around the second MCP joint, with
difficulty moving his second finger.
1. What is your diagnosis?

13. Case 3 - answer
1. Intra-articular fracture of the base of the second
proximal phalanx (see next slide).
Some of you probably spotted the fracture the first time
round anyway, but the purpose of this case is to illustrate
how important ‘localizing information’ can be in the
setting of trauma.
We frequently get referrals for ‘hand (or foot) x-ray, ?#’.
Without knowing where the problem is it can be very
difficult for a Radiologist to see fractures that are obvious
to someone who knows exactly where to look.

15. Case 4

16. Case 4
• 40 year old man with severe pleuritic chest
pain. Currently undergoing IV antibiotic
therapy for pneumonia.
1. How would you describe the abnormalities
on the CXR?
2. What is your diagnosis?
3. Give five common causes of this diagnosis.
4. How is the patient’s IV antibiotic therapy
being administered?

17. Case 4 - answers
1. There is increased lucency of the right hemithorax. Pleural lines
are visible and the lung markings do not extend all the way to the
periphery. There is an effusion at the base of the right hemithorax
however it does not show a meniscus sign (it does not curve
upward at the costophrenic margin).
2. Right hydropneumothorax. The absence of a meniscus sign in the
effusion is very helpful in some cases where the pneumothorax is
small and subtle – the meniscus sign only occurs when the lung is
fully inflated and extends all the way to the chest wall, so
whenever you see a pleural effusion with a perfectly straight line
look very carefully for a pneumothorax.
3. Causes of spontaneous (non-traumatic) pneumothorax: primary
(typically tall young males), COPD, asthma, CF, pneumonia
(uncommon, but possibly the cause in this case), α-1-antitrypsin
deficiency, Marfan syndrome.
4. There is a right-sided PICC line which was inserted so that the
patient could undergo home IV antibiotic therapy

18. Case 5

19. Case 5
• 21 year old man presented with shoulder pain
after falling off his bike.
1. What is your diagnosis?
2. What other types of dislocation (a clue to #1,
above!) can occur in the shoulder?

20. Case 5 - answer
1. Acromioclavicular dislocation. This can be subtle, as in this
example – the key to the diagnosis is knowing that the
undersurface of the distal clavicle and the undersurface of
the acromion should normally align with each other – see
next slide. Other clues to the diagnosis include widening
of the distance between the clavicle and acromion, and of
the distance between the clavicle and the coracoid
process of the scapula.
2. Anterior glenohumeral joint dislocation is the most
common form of shoulder dislocation. Posterior
glenohumeral dislocation is uncommon but should be
suspected in patients with shoulder pain following a
seizure.

21. Discordance between
undersurfaces of clavicle
and acromion
Increased coracoclavicular
distance, due to injury to
the coracoclavicular ligament

22. Case 6

23. Case 6
• 36 year old man, soccer injury.
1. What abnormalities are shown?
2. What needs to be performed urgently:
a. A CT scan
b. Application of a cast to maintain alignment as
currently shown
c. MRI
d. Manipulation to improve alignment
e. Internal fixation

24. Case 6 - answers
1. There are fractures of the medial and lateral
malleoli. The talus is dislocated laterally, relative
to the distal tibia.
2. (d) Manipulation to improve alignment. This
ankle dislocation needs to be urgently reduced –
the longer the ankle is left like this, the more
severe the associated soft tissue swelling. This
swelling can be so severe that if surgery were
performed, it would not be possible to close the
wounds.

25. Case 7

26. Case 7
• 24 year old woman, fell while ice-skating.
1. What abnormality is shown?
2. The orthopaedic team want to be certain
that there aren’t any associated fractures –
what imaging test would you suggest be
performed next?

27. Case 7 - answer
1. There is posterior dislocation of the right elbow
(see magnified slide, next). Almost all elbow
dislocations occur in the posterior direction.
2. Although none is visible on this radiograph, it is
not uncommon for elbow dislocations to be
associated with fractures. The most common
fractures in this setting are of the capitellum
(from impaction by the radial head) and of the
coronoid process of the ulna (impacting against
the trochlea of the humerus). CT is ideal for
evaluating for such injuries and is performed
routinely in patients with elbow dislocations.

28. Radial head (R) is dislocated
posterior to capitellum (C)
R
C
Proximal ulna is
dislocated posterior to
trochlea of distal
humerus

29. Case 8

30. Case 8
• 28 year old man, twisted ankle while playing
Gaelic football.
1. What are the radiographic findings and what
is the diagnosis?
2. The ED SHO thinks there are two fractures
and asks your opinion – what would you tell
her about the second ‘abnormality’?

31. Case 8 - answers
1. There is an oblique lucency passing through the distal
fibula at the level of the syndesmosis (same level as ankle
joint) with some overlying soft tissue swelling, indicating a
Weber B fracture. (Weber A is below the syndesmosis,
Weber C is above it).
2. The bone fragment inferior to the lateral malleolus is well-
corticated and cannot be an acute fracture. This is called
an ‘os subfibulare’ and is one of over a dozen accessory
ossicles that are commonly found in the foot and ankle.
These ossicles are usually asymptomatic but are
important to know about because they are often
misinterpreted as fracture fragments. The way we tell the
difference is by the looking at the edges of the fragment –
if there is a clearly-defined cortex all the way around it
then it cannot be an acute injury.

32. Os subfibulare
Fracture

33. Case 9

34. Case 9
• 72 year old woman, pyrexial with productive
cough and pleuritic chest pain.
1. Describe the abnormalities on this CXR.
2. What is your diagnosis?
3. What part(s) of the lung do you think are
involved?

35. Case 9 - answers
1. PA CXR shows increased opacification in the left lower
zone. The normal silhouette of the left
hemidiaphragm is absent, as is the inferior aspect of
the left heart border. The opacity appears
predominantly alveolar (airspace) however it is much
denser at the lung base, and a meniscus sign is also
evident here.
2. Pneumonia with parapneumonic effusion.
3. In this case, because we’re not able to see the left
hemidiaphragm or the entire left heart border, it is
likely that there is involvement of both the lower lobe
and of the lingula of the upper lobe.

36. Case 10

37. Case 10
• 22 year old man, brought to ED by ambulance
following a rugby injury.
1. What factors do we have to consider when
we’re describing a fracture?
2. How would you describe this patient’s injury?

38. Case 10
1. For every fracture, there are several important things to consider
when describing the injury - it is not sufficient to simply indicate
the site of the fracture.
• Open (compound) or closed?
• Comminuted (more than two fragments)?
• Does it involve the articular surface?
• Orientation (transverse, longitudinal, oblique, spiral)?
• Angulated (which direction)?
• Displaced (which direction)?
• Is there an associated dislocation?
2. This man has a comminuted fracture of the proximal
diametaphysis of the tibia. It does not involve the articular
surface. The fracture is posteriorly displaced (based on the
position of the distal fragment). Most importantly, there is gas
(lucency) in the soft tissues around the fracture, and also in the
knee joint, indicating that this is an open fracture.

39. Gas in knee joint
Gas in soft tissues
around fracture
Multiple fracture fragments,
indicating comminution

40. Case 11

41. Case 11
• 19 year old man, staggered back across the
Liffey having been stabbed on the Northside.
1. Describe the radiographic findings.
2. What is your diagnosis?
3. On seeing this CXR, you go to see if the
patient is still in the Radiology Department
and find him unconscious – what would you
do next?

42. Case 11 - answers
1. There is markedly increased lucency in the right
hemithorax, with no lung markings visible – the right
lung has almost completely collapsed towards the
hilum. There is a small pleural effusion, with no
meniscus sign. The trachea is displaced to the left of
midline (relative to the spinous processes), and the
heart is also displaced to the left.
2. Tension pneumothorax.
3. Place a large bore (14-16G) IV cannula through the 2nd
anterior intercostal space. Arrange urgent definitive
chest drain placement.

43. Trachea shifted to
left of spinous processes
Collapsed lung
Effusion

44. Case 12

45. Case 12
• 17 year old male, punched in left side of face.
Complaining of pain, swelling, and blurred
vision.
1. Describe the salient abnormality.
2. What secondary radiographic sign(s) of the
above do you know of, and which of them is
present in this case.
3. Given the patient’s diplopia, what would you
recommend next and why?

46. Case 12 - answers
1. There is a step in the floor of the left orbit, indicating
a fracture.
2. Helpful signs which may allow us to diagnose an
otherwise subtle orbital floor fracture are:
• An air-fluid level in the maxillary sinus (present in this
case), caused by haemorrhage into the sinus
• A lucency in the orbit above the globe (orbital
emphysema) due to air leaking from the sinus
3. A CT facial bones should be arranged, to assess for
additional fractures and to look for herniation of the
inferior rectus muscle through the orbital floor (an
orbital blow-out fracture)

47. Fracture
Air-fluid level

48. Case 13

49. Case 13
• 77 year old male, presenting with dyspnoea
on minimal exertion.
1. Describe the abnormalities on the CXR.
2. What is your diagnosis?

50. Case 13 - answers
1. The heart is mildly enlarged. There is bilateral
perihilar alveolar opacification and there is
upper lobe pulmonary venous diversion.
Multiple fine linear opacities are
demonstrated in the peripheries of both
lungs, in keeping with Kerley B lines. There
are no pleural effusions.
2. Cardiogenic pulmonary oedema.

51. Upper lobe venous diversion
Fluffy perihilar alveolar infiltrates
Kerley B lines

52. Case 14

53. Case 14
• 24 year old woman, pain following fall on
outstretched hand.
1. What is the diagnosis?
2. What secondary signs are present here that
support the diagnosis?
3. What might we see at the wrist in some cases of
this injury?
4. What pattern of injury do we see in (a)
Monteggia and (b) Galeazzi fracture-
dislocations?

54. Case 14 - answers
1. There is an intra-articular fracture of the radial head.
2. There is an anterior sail sign, caused by a haemarthrosis in the elbow
joint, and there is also displacement of the posterior fat pad (which
should never be visible in a normal elbow).
3. In Essex-Lopresti fracture-dislocation injuries, the radial head fracture
is associated with dislocation of the distal radio-ulnar joint.
4. (a) Monteggia: fracture of the ulnar shaft with dislocation of the
radial head
(b) Galeazzi: fracture of distal radius with dislocation of distal radio-
ulnar joint
These fracture-dislocation patterns are important to be aware of as the
fracture is usually the most painful component, and the dislocation may
therefore be missed, leading to long-term functional problems

55. Fracture
Sail sign
Displaced posterior fat pad

56. Case 15

57. Case 15
• 60 year old man, portable AP erect CXR.
1. What hardware can you identify?
2. Can you spot two significant abnormalities?

58. Case 15 - answers
1. Hardware:
• Defibrillator pads (always an ominous sign)
• Right internal jugular line
• Pulmonary arterial catheter
• Endotracheal tube
• NG tube (tip not seen)
2. Abnormalities
• Right pneumothorax – a complication of the right
internal jugular line insertion
• Pneumoperitoneum – the patient was recently post-
laparotomy (liver transplant)

59. Pleural line due to
small pneumothorax
Right IJV line
ET tube
NG tube
Tip of pulmonary
arterial catheter
Defib pads
Gas under right hemidiaphragm

60. Case 16

61. Case 16
• 55 year old woman, presenting with cough
and fever.
1. Describe the radiographic abnormalities.
2. What is the diagnosis, and why?
3. How are the ‘zones’ of the lungs defined?

62. Case 16 - answers
1. PA and right lateral CXR. There is abnormal
opacification in the right mid- and upper-zones,
sharply demarcated at its inferior margin on the PA
study, and at its inferior and posterior margins on the
lateral view.
2. Right upper lobe pneumonia. We know that it is the
upper lobe that is affected as it is above the
horizontal fissure, and anterior to the oblique fissure.
3. The upper zone the area above the anterior aspect of
the second rib, the mid-zone is between the anterior
aspects of the second and fourth ribs, while the lower
zone is below the anterior aspect of the fourth rib.

63. Horizontal fissure Oblique fissure

64. Case 17

65. Case 17
• 78 year old woman, fell in nursing home and
now unable to weight bear.
1. There are two abnormalities on this film, one
acute and one old – can you identify them?
2. When a hip fracture is clinically suspected
but not identified on radiographs, what
imaging options are available to us?

66. Case 17 - answers
1. There is an acute, mildly displaced subcapital fracture
of the left proximal femur. There is an old, healed
fracture of the left inferior pubic ramus. These
findings suggest that the patient may be osteoporotic
and a DXA should be recommended if this has not
already been diagnosed.
2. CT is usually the first test that is performed when
radiographs have not shown a clinically suspected
fracture. In a very small percentage of osteoporotic
patients with hip fractures, CT will also be falsely
negative and in those patients we can perform either
a bone scan or an MRI (MRI has 100% sensitivity for
pelvic/femoral fractures but is not performed
routinely because of availability and cost issues).

67. Subcapital fracture
Healed inferior pubic ramus fracture

68. Case 18

69. Case 18
• 65 year old woman, fell on ice, unable to
move right arm.
1. How would you describe this fracture?

70. Case 18 - answer
1. There is a comminuted fracture of the surgical
neck of the right humerus, also involving the
greater tuberosity. The fracture is impacted (the
proximal part of the humeral shaft has been
displaced superior to its normal position). The
humeral head remains in articulation with the
glenoid but is slightly subluxed inferiorly – this is
a common finding in shoulder fractures, and is
in part related to the presence of a
haemarthrosis in the joint, pushing the head
inferiorly.

71. Humeral head subluxed inferiorly,
relative to glenoid
Greater tuberosity
fracture
Surgical neck
fracture

72. Case 19

73. Case 19
• 33 year old woman, presented with tender red
lumps on her lower limbs.
1. How would you describe this CXR?
2. What is the diagnosis in this case?
3. How is this condition staged radiographically,
and what stage is this patient?

74. Case 19 - answers
1. There is marked enlargement of both hila. The heart
and mediastinum are normal. Both lungs are also
normal and there are no pleural effusions.
2. Bihilar lymphadenopathy – sarcoidosis.
3. Stage 0 – normal CXR
Stage I – nodal enlargement only
– most common stage at presentation, and the stage of this patient
Stage II – parenchymal abnormalities only
Stage III – nodal and parenchymal disease
Stage IV – pulmonary fibrosis

75. Case 20

76. Case 20
• 54 year old man, fell off a ladder and landed
on his left side.
1. How would you describe this CXR?
2. What is the diagnosis in this case?
3. This patient had a history of previous trauma
– can you identify the old injury?

77. Case 20 - answers
1. There is increased lucency of the left
hemithorax, lung markings are not visible at all
in the upper zone or the periphery of the lower
zone, and pleural lines are demonstrated. There
is a subtle horizontal effusion, with no meniscus.
The trachea, heart and mediastinum are shifted
to the right of midline.
2. Another tension pneumothorax (you can never
see enough examples of pneumothoraces).
3. Old left clavicle fracture.

78. Old clavicle fractureNo lung markings
Tracheal shift
Pleural line
Effusion

79. Case 21

80. Case 21
• 74 year old man, fell down stairs and
complaining of severe back pain.
1. What is the abnormality?
2. What test would you recommend next and
why?
3. It is often difficult to determine whether
these injuries are new or old – what can we
do to differentiate?

81. Case 21 - answers
1. There is a wedge compression fracture of the T7 vertebral
body with associated kyphosis.
2. CT is routinely performed next in the work-up of vertebral
fractures. It shows the full extent of the fracture, whether
the posterior elements are involved, whether the fracture
is stable or unstable and whether there is retropulsion of
bone fragments into the spinal canal, which might
compress the spinal cord.
3. Even with CT, it can be hard to work out whether a
vertebral fracture is new. If we have a recent radiograph
to compare to, that may be enough to confirm acuity. If
none are available, and it is important to know whether
the fracture is recent (i.e. it would alter management), an
MRI or a bone scan will provide the answer.

82. Wedge-shaped fracture

83. Emergency Radiology Quiz Cases
Quiz complete, well done!