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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

Name the Cardiac Device • Xray of the Week Figure 1. Name the cardiac device. Figure 2. A: Plain radiograph demonstrating the TMVR (red arrows). Note on the plain xray that the long axis of the TMVR replacement is more horizontal than seen with TAVR B: Axial CT image of the chest showing TMVR (yellow arrows). C: Coronal CT image of the chest showing TMVR (green arrows). Figure 3. Video demonstrating transapical placement technique for Transcatheter Mitral Valve Replacement (Neovasc). Figure 4. A: Plain radiograph demonstrating TAVR (red arrows). Note on the plain xray that the long axis of the TAVR replacement is more vertical than seen with TMVR B: Axial CT image of the chest showing TAVR (green arrow). Note the location of the normal mitral valve (yellow arrows) C: Coronal CT image of the chest showing TAVR (green arrow). Discussion: Mitral regurgitation (MR) is the most common type of mitral valve disease in developed nations, and mitral valve disease itself is the second most common valvular heart disease within adults. Untreated MR can lead to systolic and diastolic congestive heart failure (CHF) with an annual mortality rate of 5%. Treatment options for MR include both surgical and minimally invasive approaches. The latter of these approaches includes both the MitraClip (transcatheter mitral valve repair technique or TMVr) or transcatheter mitral valve replacement (TMVR) (Figs. 1-3). Currently only TMVr via MitraClip is FDA approved and remains the standard of care, but this approach is limited in use due to the small proportion of suitable patients. Unlike the MitraClip, TMVR has been mostly experimental and while over 30 different systems are in development, only a few of these technologies have reached early feasibility studies in humans including but not limited to the Tendyne MV system, Sapien 3 and Highlife Valve. Transseptal, transapical and transfemoral approaches have been used for placement of these prosthetic valves (Fig. 3). All of the valves are comprised of 3 bovine or porcine leaflets in an expandable stentframe (Fig. 3). Imaging for mitral valve replacement falls into 3 main categories, pre-procedural, intra-procedural, and post-procedure. Due to the complex anatomical structure of the mitral valve, placement is more complicated than that of the aortic valve (Fig. 4). Intra-procedural imaging via fluoroscopy is used to ensure proper placement and deployment of the prosthesis. Due to the limitations of fluoroscopy, pre-procedural imaging via 2D echocardiography and angiography are crucial for success. Multidetector CT (MDCT), which provides a 3D reconstruction of the valve allowing for detailed measurements, has gained use in pre-procedural imaging as well. Recent studies have shown that even 3D TEE compared to 2D echo allow for better evaluation and flow convergence. In addition to its complex geometry, the mitral valve in identifying soft tissue structures, imaging will be inadequate in a mitral valve with a lack of calcifications. Thus, TEE also plays a role in intra-procedural imaging as well as immediately following deployment and identifying potential complications such as tamponade, septal rupture, and coronary sinus trauma. While crossover of Transcatheter Aortic Valve Replacement TAVR technologies and approaches continue to aid in the development of similar TMVR devices, several key differences do exist that limit this. Included within these differences are patient age in that MR patients tend to be much younger than Aortic Stenosis (AS) patients, disease etiology, and the benefit of conservative therapy. Complications of TMVR include left ventricular outflow tract valve displacement, cardiovascular mortality, device malfunction, and stroke. On plain radiographs a TMVR prosthesis can easily be misidentified as a TAVR and that studies have shown that the “imaginary line method” may not be a reliable method of discerning between the two. Rather use of the “valve orifice” or “perceived direction of blood flow” methods should be employed. As seen in this case, CT is definitive in discerning the valve location (Fig. 4). ​​​​ References: 1. Kelley C, Lazkani M, Farah J, Pershad A. Percutaneous mitral valve repair: A new treatment for mitral regurgitation. Indian Heart J. 2016;68(3):399-404. doi:10.1016/j.ihj.2015.08.025 2. Meng Z, Zhang E-L, Wu Y-J. Current Status and Future Direction of Transcatheter Mitral Valve Replacement. Chin Med J (Engl). 2018;131(5):505-507. doi:10.4103/0366-6999.226080 3. Alkhouli M, Alqahtani F, Aljohani S. Transcatheter mitral valve replacement: an evolution of a revolution. J Thorac Dis. 2017;9(Suppl 7):S668-S672. doi:10.21037/jtd.2017.05.60 4. Ramlawi B, Gammie JS. Mitral Valve Surgery: Current Minimally Invasive and Transcatheter Options. Methodist Debakey Cardiovasc J. 2016;12(1):20-26. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4847963/ 5. Foot CL, Coucher J, Stickley M, Mundy J, Venkatesh B. The imaginary line method is not reliable for identification of prosthetic heart valves on AP chest radiographs. Crit Care Resusc. 2006;8(1):15-18. https://www.ncbi.nlm.nih.gov/pubmed/16536714 6. del Val D, Ferreira‐Neto AN, Wintzer‐Wehekind J, et al. Early Experience With Transcatheter Mitral Valve Replacement: A Systematic Review. Journal of the American Heart Association. 2019;8(17):e013332. doi:10.1161/JAHA.119.013332 7. Natarajan N, Patel P, Bartel T, et al. Peri-procedural imaging for transcatheter mitral valve replacement. Cardiovasc Diagn Ther. 2016;6(2):144-159. doi:10.21037/cdt.2016.02.04 Related posts: Mitraclip Cardiac Device Transcatheter Aortic Valve Replacement (TAVR) CardioMEMS Device 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 is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. 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 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

Name the Cardiac Device • Xray of the Week Figure 1. Name the cardiac device. Figure 2. A: Plain radiograph demonstrating the TAVR (red arrows). Note on the plain xray the TAVR aligning with the expected location of the aortic root. B: Axial CT image of the chest showing TAVR (green arrow). Note the location of the normal mitral valve (yellow arrows) C: Coronal CT image of the chest showing TAVR (green arrow). Figure 3. Video demonstrating placement technique for TAVR (Edwards Sapien 3). Discussion: Aortic valve replacement via surgical (surgical aortic valve replacement or SAVR) and minimally invasive approaches (transcatheter aortic valve replacement or TAVR) have become the gold standard in treatment for patients with severe aortic stenosis (AS). Prior to TAVR, which was FDA approved in 2011 for severe AS, the only nonsurgical options available to patients were diuretics and balloon valvuloplasty – neither of which effected long term events. Indications for aortic aalve (AV) replacement include patients with symptoms, and those who are asymptomatic with LVEF less than 50%. Imaging plays a crucial role before, during and after the procedure, and especially with TAVR as there is decreased visualization with this procedure compared to SAVR. Pre-op imaging remains a crucial aspect to TAVR as the aortic valve maintains a complex geometrical structure making measurements a hard task. Additionally, in severe AS the valve annulus may morph in shape which can lead to an underestimation of size. Thus, 3D transesophageal echocardiography (TEE) and multi-detector computed tomography (MDCT) remain the modalities of choice. Studies have specifically shown that TEE measurements are best obtained during mid-systole and while MDCT measurements can be obtained at any point during the cycle, they best correspond to those of TEE when obtained during diastole. There does remain some concern though that 3D TEE tends to underestimate to the tune of 9-12% compared to MDCT, thus overall MDCT tends to be utilized more in practice. Peri-procedural imaging has traditionally relied upon guidance via TEE requiring general anesthesia but as the shift from general anesthesia towards conscious sedation is being made for the procedure, imaging is now largely done via fluoroscopic guidance. Each modality, TEE, TTE with fluoroscopy, and fluoroscopy alone have all been used for real time imaging during the procedure, and each has its own benefits and downfalls. Post-procedural imaging relies strongly on a multi-modal imaging approach by way of echocardiography, cardiac CT, and cardiac magnetic resonance imaging, all of which play important roles in discerning between various post-op complications. Suspected paravalvular leak and valvular thrombosis are best imaged via echo and CMR or echo and CCT, respectively. Structural deterioration is best seen via CCT. ​​​​ References: 1. Corrigan FE, Gleason PT, Condado JF, et al. Imaging for Predicting, Detecting, and Managing Complications After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Imaging. 2019;12(5):904-920. doi:10.1016/j.jcmg.2018.07.036 2. Xu B, Mottram PM, Lockwood S, Meredith IT. Imaging Guidance for Transcatheter Aortic Valve Replacement: Is Transoesophageal Echocardiography the Gold Standard? Heart Lung Circ. 2017;26(10):1036-1050. doi:10.1016/j.hlc.2017.02.018 3. Bleakley C, Monaghan MJ. The Pivotal Role of Imaging in TAVR Procedures. Curr Cardiol Rep. 2018;20(2). doi:10.1007/s11886-018-0949-z 4. Ramlawi B, Anaya-Ayala JE, Reardon MJ. Transcatheter Aortic Valve Replacement (TAVR): Access Planning and Strategies. Methodist Debakey Cardiovasc J. 2012;8(2):22-25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405802/ 5. Mahmaljy H, Tawney A, Young M. Transcatheter Aortic Valve Replacement (TAVR/TAVI, Percutaneous Replacement). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. http://www.ncbi.nlm.nih.gov/books/NBK431075/. Accessed March 20, 2020. Related posts: Bicuspid Aortic Valve and Aortic Stenosis Transcatheter Mitral Valve Replacement (TMVR) CardioMEMS Device 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 is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. 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 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

45 year old male with chest pain, tachypnea and shortness of breath • Xray of the Week Figure 1. Name the important findings on this CT Scan. Figure 2. CT Scan demonstrating saddle pulmonary embolism with RV strain. A: Saddle embolism (red arrow). Large bilateral emboli in right and left main pulmonary arteries (yellow and green arrows). B: RV strain with dilated RV, bowing of the interventricular septum to the left (blue arrows). Figure 3. CT Scan demonstrating saddle pulmonary embolism with RV strain. A: Saddle embolism and dilated main pulmonary artery which is larger than the ascending aorta. B: RV strain with dilated RV, measuring larger than LV. C: Bowing of the interventricular septum to the left (yellow arrows). Discussion: Due to its high sensitivity and specificity, CT pulmonary angiography (CTPA) has become the imaging modality of choice in diagnosis of pulmonary embolism (PE) and has replaced VQ scanning within treatment algorithms (1,2). CTPA allows for a more accurate evaluation of clot size, extent of clot, underlying lung disease and evaluation of potential right ventricular (RV) strain. In addition, in up to 40% of patients CT demonstrates other pathology responsible for the patient's clinical picture (3-5). CT findings of PE include a central filling defect, vessel cut off, and rim sign. Multiple emboli are more common than solitary and lower lobes are usually more affected than upper lobes. Secondary findings on CT may include pulmonary infarct, hemorrhage, upper extremity DVT, hypoperfusion, atelectasis, and RV strain. An RV/LV ratio greater than one and leftward bowing of the ventricular septum are indicative of RV strain (5). A dilated RV is the most accurate and reproducible method of evaluating RV strain (5). Although, leftward bowing of the ventricular septum and inferior vena cava contrast reflux are also predictive of adverse outcomes (3). After myocardial infarction and stroke, pulmonary embolism is the 3rd leading cause of mortality due to cardiovascular disease. Mortality from RV failure is most often due to PE (4). Mortality rate is as high as 50-58% in those with hemodynamic instability and 8-15% in those without (4). The mainstay of treatment is cardiopulmonary support and anticoagulation; however, thrombolysis may play a role in cases with massive PE and cardiovascular compromise (6). Patients who can not be anticoagulated require an IVC filter. ​​​​ References: 1. Ghaye B, Ghuysen A, Bruyere P-J, D’Orio V, Dondelinger RF. Can CT Pulmonary Angiography Allow Assessment of Severity and Prognosis in Patients Presenting with Pulmonary Embolism? What the Radiologist Needs to Know. RadioGraphics. 2006;26(1):23-39. doi:10.1148/rg.261055062 2. He H, Stein MW, Zalta B, Haramati LB. Computed tomography evaluation of right heart dysfunction in patients with acute pulmonary embolism. J Comput Assist Tomogr. 2006;30(2):262-266. doi:10.1097/00004728-200603000-00018 3. Kang DK, Thilo C, Schoepf UJ, et al. CT Signs of Right Ventricular Dysfunction: Prognostic Role in Acute Pulmonary Embolism. JACC: Cardiovascular Imaging. 2011;4(8):841-849. doi:10.1016/j.jcmg.2011.04.013 4. Kostadima E, Zakynthinos E. Pulmonary Embolism: Pathophysiology, Diagnosis, Treatment. Hellenic J Cardiol 48: 94-107, 2007 5. Kang DK, Ramos-Duran L, Schoepf UJ, et al. Reproducibility of CT Signs of Right Ventricular Dysfunction in Acute Pulmonary Embolism. American Journal of Roentgenology. 2010;194(6):1500-1506. doi:10.2214/AJR.09.3717 6. Araoz PA, Gotway MB, Harrington JR, et al. Pulmonary Embolism: Prognostic CT Findings. Radiology 2007;242:889-897 https://doi.org/10.1148/radiol.2423051441 Related posts: Transcatheter Mitral Valve Replacement (TMVR) CardioMEMS Device 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 is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. 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 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

Name the finding on bladder ultrasound and related complication • Xray of the Week Figure 1. Bladder ultrasound. Figure 2. Bladder ultrasound- sagittal image. Note the intra-vesicular ureterocele seen as a cystic dilation of the distal ureter bulging into the bladder. There is also a dilated distal ureter due to obstruction. Discussion: Ureteroceles form due to the cystic dilation and out-pouching of the distal ureter and may result in ureteral obstruction and impaired renal function. Patients may present asymptomatically or with signs related to obstructed urine outflow such as recurrent urinary tract infections, and renal failure. Classification of ureteroceles is based on location as either intra or extra vesicular. Any child with a urinary tract infection should undergo screening with bladder ultrasound (US) which will typically help identify this congenital anomaly. If US fails to show any deformities, voiding cystourethrogram (VCUG) should be considered and especially in cases of colonization by organisms other than E.coli and in cases of recurrent UTI (1,2). Ultrasound characteristics of ureteroceles include identification of an ectopic cystic mass, typically near the vesicoureteral junction (VUJ). Radiologic characteristics of ureteroceles consist of a round filling defect near the VUJ and the classical ‘cobra head sign’ that resembles a snake’s head bulging into the bladder. The ‘cobra head sign’ is typically seen with intravesical ureteroceles and is characterized by dilation of the distal ureter (cobra head) with a surrounding radiolucent halo that is seen within contrast-filled bladders on intravenous urograms (1,3). Symptomatic ureteroceles are typically managed via cystoscopic transurethral incision (4). ​​​​ References: 1. Adesiyun. Bilateral giant orthotopic ureterocele appearing as kissing cobra in a Nigerian child. Accessed May 8, 2020. http://www.wajradiology.org/article.asp?issn=1115-3474;year=2015;volume=22;issue=1;spage=42;epage=44;aulast=Adesiyun 2. Schultza K, Todab LY. Genetic Basis of Ureterocele. Curr Genomics. 2016;17(1):62-69. doi:10.2174/1389202916666151014222815 3. Genitourinary Radiology. Accessed May 8, 2020. https://www.med-ed.virginia.edu/courses/rad/gu/embryology/ureterocele.html 4. Gottlieb C, Beranbaum SL, Hamilton RH. Radiographic Features of Ureterocele. Radiology. 1953;60(1):64-67. doi:10.1148/60.1.64 Neal Shah is a medical student at The Edward Via College of Osteopathic Medicine (VCOM)–Carolinas and intends on completing his residency within the field of radiology. 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 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

46 year old female with right upper quadrant pain and jaundice. Diagnosis? • Xray of the Week Figure 1. What are the important findings? Figure 2 A: Transverse ultrasound of RUQ. Hyperechoic shadowing gallstone within lumen of gallbladder (green arrow) with diffuse irregular wall thickening (red arrows). B: T1 weighted axial MRI with contrast. Irregularly thickened enhancing gallbladder wall (red arrows). C: CT Abdomen with contrast, coronal reconstruction. Irregular mass with heterogenous enhancement (red arrows). Gallstone within lumen of gallbladder (green arrow). D: T1 weighted coronal MRI. Irregularly thickened enhancing gallbladder wall (red arrows). Gallstone in fundus of gallbladder (green arrow). Discussion: Gallbladder carcinoma is the most common malignancy of the biliary tract and is associated with a mean survival of 6 months from diagnosis (1). The poor prognosis is due to late diagnosis, often with advanced disease as a result of the nonspecific symptoms with which the cancer may present. Risk factors include, Native American and Southeast Asian descent, female gender, and history of inflammation of the gallbladder, from gallstones, parasitic illness or primary sclerosing cholangitis (1,2). Figure 3. Porcelain gallbladder in a different patient. Plain radiograph Endoscopic ultrasonography is the optimal modality for staging (1). However, symptomatic patients may get an initial abdominal radiograph, which can show gas production from invasion into bowel or fistula formation or a heterogenous pattern from tumor necrosis (3). Findings suggestive of malignancy can include porcelain gallbladder, characterized by calcium deposition in the gallbladder wall, which is associated with underlying carcinoma in 25% of patients (Fig. 3). Furthermore, wall thickness greater than 3 mm should raise an index of suspicion, although diffuse wall thickening can be associated with other inflammatory conditions such as cholecystitis and adenomyomatosis (4). Focal or diffuse asymmetric wall thickening greater than 3 mm can be concerning for underlying carcinoma, with increased likelihood of malignancy when there is marked enhancement of the wall during the arterial phase and isointensity in the venous phase on CT and MRI (5). Increased vascularity and the presence of polyps are most often benign and secondary to cholesterol or inflammation, but may have malignant potential (6,7). Resection is indicated for polyps greater than 1 cm (5). CT can be utilized to depict lymphadenopathy, regional spread to liver or metastasis (1). CT can also serve in highlighting regions of the gallbladder that may be poorly visualized on ultrasound, when there are gallstones or mural calcification present (5). A CT demonstrating a weakly enhancing outer layer and thicker inner layer of gallbladder wall is highly suggestive of malignancy (4). On CT, gallbladder carcinoma can present as a polyploid mass within the lumen, focal or diffuse thickening or with a mass replacing the gallbladder (2,3). MRI/MRCP can show vascular or bile duct invasion (3). ​​​​ References: Hundal, R., & Shaffer, E. A. (2014). Gallbladder cancer: epidemiology and outcome. Clinical epidemiology, 6, 99–109. doi:10.2147/CLEP.S37357 Kanthan R, Senger JL, Ahmed S, Kanthan SC. Gallbladder Cancer in the 21st Century. J Oncol. 2015;2015:967472. doi:10.1155/2015/967472 Levy AD, Murakata LA, Rohrmann CA Jr. Gallbladder carcinoma: radiologic-pathologic correlation [published correction appears in Radiographics 2001 May-Jun;21(3):766]. Radiographics. 2001;21(2):295-555. doi:10.1148/radiographics.21.2.g01mr16295 Kim SJ, Lee JM, Lee JY, et al. Analysis of enhancement pattern of flat gallbladder wall thickening on MDCT to differentiate gallbladder cancer from cholecystitis. AJR Am J Roentgenol. 2008;191(3):765-771. doi:10.2214/AJR.07.3331 Andrén-Sandberg Å. Diagnosis and management of gallbladder cancer. North Am J Med Sci 2012;4:293-299. doi:10.4103/1947-2714.98586 Mitchell CH, Johnson PT, Fishman EK, Hruban RH, Raman SP. Features suggestive of gallbladder malignancy: analysis of T1, T2, and T3 tumors on cross-sectional imaging. J Comput Assist Tomogr. 2014;38(2):235-241. doi:10.1097/RCT.0b013e3182aafb6b Rooholamini SA, Tehrani NS, Razavi MK, et al. Imaging of gallbladder carcinoma. Radiographics. 1994;14(2):291-306. doi:10.1148/radiographics.14.2.8190955 Usha Trivedi is a medical student at Rutgers New Jersey Medical School with aspirations to become a diagnostic radiologist. She completed her undergraduate education at The College of New Jersey with a major in Biology and a minor in Art History. She is drawn to radiology due its unique blend of technology, art and medicine that is rooted in patient care. Her first exposure to radiology was through clerkships in medical school, where she saw how crucial imaging can be for patient care. She is currently involved as a director for one of her medical school’s student-run clinics and with her medical school’s humanities-themed magazine. She aspires to become a radiologist with specific interests in mentorship, education and advocacy. In her spare time, she enjoys hiking, reading, art and board games. Follow Usha Trivedi on Twitter @UshaTrivedi11. All posts by Usha Trivedi Kevin M. Rice, MD is the president of Global Radiology CME Dr. Rice is a radiologist with Renaissance Imaging Medical Associates. He has held several leadership positions including Chair of Radiology, Board of Directors, 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. Follow Dr. Rice on Twitter @KevinRiceMD All posts by Kevin M. Rice, MD

8 Year Old Male With Trauma Due To A Fall. Diagnosis? • Xray of the Week Figure 1. What is the important finding? Figure 2 A: AP view radiograph of right forearm. Acute transverse fracture of distal radius visualized (green arrow). B: Lateral radiograph view of right forearm. Angulation of ulna visualized (red arrows). Discussion: The above imaging findings occurred in an 8-year-old child with a trauma after a fall. An angulated fracture of the distal midshaft radius is also visualized, but there is also bowing of the ulna that is more appreciated on the lateral radiograph view. Forearm fractures are common in pediatric populations, likely due to the intrinsic elasticity and uniquely thinner cortex as compared to adult bones [1]. Radiographically, bowing fractures may show visible bending on radiographic imaging, however, as in this case if the bending occurs within the same plane of the radiograph, there may be no visible deformities on radiographic imaging [2]. Unlike other fractures, plastic bowing fractures do not produce a characteristic fracture line, but rather can produce subtle angular changes that appear as “bending” of the bone [3]. Additionally, in contrast to other fractures, the subsequent healing process for a bowing fracture does not involve a periosteal reaction [4]. As seen in this patient, bowing fractures can also be associated with a conventional fracture in the paired bone. The fracture often manifests in children who present with localized symptoms of pain and swelling after falls on an outstretched hand, and in many cases, the child is playing or participating in common childhood activities like climbing monkey bars or jumping. Plastic bowing fractures most commonly occur in the forearm, but may also be found in the clavicle, fibula, and other long bones. The mechanism of injury often entails an angulated force on the bone producing longitudinal compression, that exceeds the intrinsic elasticity of the bone [4] . Most fractures that disrupt the cortical makeup of a bone exceed intrinsic plasticity, which produces classical fractures [4]. However, due to the natural growth patterns of the bone in pediatric populations, the response of the bone to a force exceeding the elastic injury is a response of bowing, which occurs proportionally to the force [4]. Microscopically, there are microfractures occurring along the bowing edge of the bone, but this is often not appreciated on the radiograph [3]. The bowing often appears fluid-like. Intervention is often not required in most cases, unless when angulation is measured to more than 10 degrees or in children older than 10 years [5, 6]. The decision for reduction may be a dilemma for clinicians, as increased angulation and older age of children may be associated with long-term osteoarthritis [7]. Other differentials that may be considered are buckle fractures, physiological bowing, stress fractures, and greenstick fractures. Due to the subtle presentations of these fractures on radiographs, clinicians need to maintain a high index of suspicion for these injuries in susceptible pediatric populations. ​​​​ References: Kalkwarf HJ, Laor T, Bean JA. Fracture risk in children with a forearm injury is associated with volumetric bone density and cortical area (by peripheral QCT) and areal bone density (by DXA). Osteoporos Int. 2011;22(2):607-616. doi:10.1007/s00198-010-1333-z Sawkar, A.; Swischuk, L; Jadhav, S. Plastic Bending Fractures in Children, Contemporary Diagnostic Radiology: 2011; (34): 1-6. doi:10.1097/01.CDR.0000406379.59531.8d Crowe JE, Swischuk LE. Acute bowing fractures of the forearm in children: a frequently missed injury. AJR Am J Roentgenol. 1977;128(6):981-984. doi:10.2214/ajr.128.6.981 Borden S 4th. Roentgen recognition of acute plastic bowing of the forearm in children. Am J Roentgenol Radium Ther Nucl Med. 1975;125(3):524-530. doi:10.2214/ajr.125.3.524 Vorlat P, De Boeck H. Bowing fractures of the forearm in children: a long-term followup. Clin Orthop Relat Res. 2003;(413):233-237. doi:10.1097/01.blo.0000072901.36018.25 Vervaecke AJ, Nuyts R, Sys J. The importance of adequate diagnosis of pediatric forearm bowing fractures: A case report. Trauma Case Rep. 2021;34:100508. doi:10.1016/j.tcr.2021.100508 Dhillon PS, Currall V, Shannon MN. Traumatic plastic deformation of the tibia: case report and literature review. Ann R Coll Surg Engl. 2012;94(1):e30-e32. doi:10.1308/003588412X13171221498947 Usha Trivedi is a medical student at Rutgers New Jersey Medical School with aspirations to become a diagnostic radiologist. She completed her undergraduate education at The College of New Jersey with a major in Biology and a minor in Art History. She is drawn to radiology due its unique blend of technology, art and medicine that is rooted in patient care. Her first exposure to radiology was through clerkships in medical school, where she saw how crucial imaging can be for patient care. She is currently involved as a director for one of her medical school’s student-run clinics and with her medical school’s humanities-themed magazine for her medical school. She aspires to become a radiologist with specific interests in mentorship, education and advocacy. In her spare time, she enjoys hiking, reading, art and board games. Follow Usha Trivedi on Twitter @UshaTrivedi11. All posts by Usha Trivedi 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