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Case Notes

History

64 day old female; cries when right leg is moved.

Exam

AP and lateral right leg.

Prior Study

None.

Dicom

Findings

You scored: 0 / 33

Technique:	Correct Answer	Your Answer
The exam is over or under penetrated.	No	NA
The exam is limited by overlying structures or soft tissues, body habitus, patient positioning, support devices, or motion.	Yes	NA
The area of concern is indicated by the patient, technologist, or care provider.	Yes	NA
The area of concern is included on the exam.	Yes	NA

Soft Tissues:	Correct Answer	Your Answer
There is soft tissue swelling, indistinctness of fat/muscle planes, gas, or laceration in the area of clinical concern.	Yes	NA
There is an effusion, fat pad displacement, or fat fluid level.	No	NA
There is a radiodense or lucent foreign body.	No	NA
There are other densities, calcifications, post-surgical changes, or support devices in the soft tissues.	No	NA

Bone:	Correct Answer	Your Answer
There is a break or interruption of the continuity of the cortical or cancellous bone with or without displacement of a fracture fragment which could be from a greenstick or toddler’s fracture, or other fracture.	Yes	NA
There is abnormal angulation or bulging of the cortical surface relative to the normal cortex which could be from a buckle or torus fracture.	No	NA
There is linear or irregular lucency, or increased density, cortical depression, flattening, or collapse, with or without cortical disruption or thickening, which may be from a compression or impaction fracture, stress or insufficiency fracture, osteonecrosis (e.g. Legg-Calve-Perthes), other fracture, or from growth recovery lines.	Yes	NA
There is disruption of commonly recognized anatomical lines (e.g. iliopectineal, radiocapitellar, anterior humeral) or structures (e.g. sacral foraminal or arcuate lines).	No	NA
There is a displaced fragment which may be from avulsion by a tendon, ligament, or joint capsule or from a comminuted or other fracture.	No	NA
There is periosteal or endosteal reaction which could indicate a healing or subacute fracture, infection/inflammation, or other abnormality.	Yes	NA
There is a corner fracture or metaphyseal lesion that could be from nonaccidental trauma.	Yes	NA
The stress trabeculae or other trabeculae of the cancellous bone are interrupted or otherwise abnormal.	No	NA
There is metaphyseal abnormality (lucencies, increased density, erosion) which may be from something other than injury such as stress, metabolic disease (e.g. rickets), neoplasm (e.g. leukemia), heavy metals, inflammation, or infection.	Yes	NA
There is/are focal or multifocal lytic/lucent, blastic/sclerotic or mixed density lesion(s) or other abnormality.	No	NA
Overall bone density is increased or decreased with or without thinning or thickening of the cortical or cancellous bone.	No	NA

Growth plates, ossification centers, apophyses:	Correct Answer	Your Answer
The growth plate(s) is/are abnormal.	No	NA
There is widening of the physis from a fracture with or without displacement of the epiphysis (Salter-Harris I).	N/A	NA
There is a fracture through the physis which then extends into the metaphysis with or without angulation or displacement (S-H II).	N/A	NA
There is a fracture through the physis which then extends into the epiphysis and is intra-articular, with or without angulation or displacement (S-H III).	N/A	NA
There is a fracture through the metaphysis, physis, and epiphysis which extends into the joint space with or without angulation or displacement (S-H IV).	N/A	NA
There is narrowing of the physis from a compression fracture (S-H V).	N/A	NA
The apophysis, epicondyle, secondary ossification center, or accessory ossicle is displaced or otherwise abnormal (e.g. avulsed ASIS, medial epicondyle of the humerus, etc).	No	NA

Joints and alignment:	Correct Answer	Your Answer
There is an effusion, fat pad displacement, or fat fluid level.	No	NA
The epiphysis or subchondral bone is fractured, interrupted, flattened, compressed, impacted, displaced, or otherwise abnormal.	No	NA
There is an intra-articular loose body or chondrocalcinosis.	No	NA
The joint is widened, narrowed, dislocated, malaligned, or incongruent.	No	NA
There is pseudoarthrosis.	No	NA

Other findings:	Correct Answer	Your Answer
There are developmental changes or other anatomic variants or other existing conditions that may or may not be contributing to symptoms which can or should be further evaluated non-emergently or are otherwise incidental.	Yes	NA
The remainder of the exam is abnormal for age.	No	NA

Impression

Expert Answer

There are metaphyseal corner fractures of the right medial distal femur and medial proximal tibia which are likely from non-accidental trauma. Periosteal reaction along the medial tibial cortex is likely physiologic in a patient of this age. This could be confirmed with comparison views of the opposite lower leg.

Your Answer

Recommendations & Acuity

Recommendations

Expert Answer

Verbal communication with the ED physician regarding findings suspicious for non-accidental trauma. Recommend skeletal survey.

Your Answer

Acuity

Expert Answer

Urgent (Action Necessary in a few hours)

Your Answer

Section 2 Case391

Findings Results

You scored: 0 / 33

Technique:	Correct Answer	Your Answer
The exam is not over or under penetrated.	No	NA
The right ankle is not entirely included on the AP view.	Yes	NA
The area of concern is indicated by the provider.	Yes	NA
The area of concern is included on the exam.	Yes	NA

Soft Tissues:	Correct Answer	Your Answer
There is minimal soft tissue swelling about the right knee.	Yes	NA
There is no effusion, fat pad displacement, or fat fluid level.	No	NA
There is no radiodense or lucent foreign body.	No	NA
There are no other densities, calcifications, post-surgical changes, or support devices in the soft tissues.	No	NA

Bone:	Correct Answer	Your Answer
There is a break or interruption of the continuity of the cortical bone of the medial distal femur and medial proximal tibia which could be from metaphyseal corner fractures.	Yes	NA
There is abnormal angulation or bulging of the cortical surface relative to the normal cortex which could be from a buckle or torus fracture.	No	NA
There is a linear lucency of the medial distal femur and medial proximal tibia which could be from metaphyseal corner fractures.	Yes	NA
There is no disruption of commonly recognized anatomical lines (e.g. iliopectineal, radiocapitellar, anterior humeral) or structures (e.g. sacral foraminal or arcuate lines).	No	NA
There is no displaced fragment which may be from avulsion by a tendon, ligament, or joint capsule or from a comminuted or other fracture.	No	NA
There is periosteal reaction of the medial right tibia which could indicate a healing or subacute fracture, but is likely physiologic in a patient of this age.	Yes	NA
There are corner fractures of the medial distal femur and medial proximal tibia that are likely from nonaccidental trauma.	Yes	NA
The stress trabeculae or other trabeculae of the cancellous bone are not interrupted or otherwise abnormal.	No	NA
There are metaphyseal abnormalities of the medial distal femur and medial proximal tibia which could be from metaphyseal corner fractures.	Yes	NA
There is/are no focal or multifocal lytic/lucent, blastic/sclerotic or mixed density lesion(s) or other abnormality.	No	NA
Overall bone density is not increased or decreased with or without thinning or thickening of the cortical or cancellous bone.	No	NA

Growth plates, ossification centers, apophyses:	Correct Answer	Your Answer
The growth plate is not abnormal.	No	NA
There is widening of the physis from a fracture with or without displacement of the epiphysis (Salter-Harris I).	N/A	NA
There is a fracture through the physis which then extends into the metaphysis with or without angulation or displacement (S-H II).	N/A	NA
There is a fracture through the physis which then extends into the epiphysis and is intra-articular, with or without angulation or displacement (S-H III).	N/A	NA
There is a fracture through the metaphysis, physis, and epiphysis which extends into the joint space with or without angulation or displacement (S-H IV).	N/A	NA
There is narrowing of the physis from a compression fracture (S-H V).	N/A	NA
The apophysis, epicondyle, secondary ossification center, or accessory ossicle is not displaced or otherwise abnormal (e.g. avulsed ASIS ot AIIS, medial epicondyle of the humerus, ischium, etc).	No	NA

Joints and alignment:	Correct Answer	Your Answer
There is no effusion, fat pad displacement, or fat fluid level.	No	NA
The epiphysis or subchondral bone is not fractured, interrupted, flattened, compressed, impacted, displaced, or otherwise abnormal.	No	NA
There is no intra-articular loose body or chondrocalcinosis.	No	NA
The joint is not widened, narrowed, dislocated, malaligned, or incongruent.	No	NA
There is no pseudoarthrosis.	No	NA

Other findings:	Correct Answer	Your Answer
Periosteal reaction along the medial tibial cortex is likely physiologic in a patient of this age. This could be confirmed with comparison views of the opposite lower leg.	Yes	NA
The remainder of the exam is not abnormal for age.	No	NA