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All right. Hello everyone. Um I'm very excited to introduce. This is our final webinar in the Essentials of Radiology Series. Um We have lots of radiology trainees with us today who will be delivering a quiz. Um So if you'd like to type answers to questions, please put them in the chat function. Um If unless told otherwise. So I'll hand over to um our radiology trainees. Hi, my name is Jade and I'm an interventional Radiology register on ST four at the moment going into ST five. And we have a group of rare cohort four who will be giving you today's emergency radiology quiz. The majority of presentations is emergency. There may be a couple in there that's not technically emergencies, but it's good to know about whether you're F one F two junior, whatever stage of being a junior doctor slash resident doctor that you are, but also as medical students as well. So some of it's for interest, some of them are more obvious. Some of them are more subtle but just try your best. We'll give you approximately 10 seconds to answer, but we'll see what people put in the chat before we then move on and give answers as we go along, we've got several different presentations by different people, but I'll not say too much. Now, if you want to get on to the main bit, which is the images today. So I'll hand over to Leslie if you go to the next slides, please. Um Is that if we can go on to the next slide, please? Perfect. Um Hi guys. So my name is Nestle Han and I'm an incoming incoming F one in London. Um Next slide, please. So I'll be running through a few chest X ray cases and then pass it on to my colleagues. So this is the first um case. So I'm going to ask you to just um put in the chat box, any abnormalities that you see in this chest X ray. If you do, I'll give you a few seconds. Um Perfect. Um So yes, that's correct. Next slide. So there are no obvious abnormalities. So this is a normal chest X ray. I just put this in just for you to have a as a reference. Um What normal is. So you can compare it to the other cases that I'll be going through. Um next slide, please. So in this case, uh two and again, just a few seconds uh to note down any abnor abnormalities that you see in this chest X ray just, just put it, type it down in the chat box. OK? So next slide um So this is a left sided pneumothorax. Um You can see the visible page here and no lung markings are seen per to this line. Um This was thought to be secondary to a rib fracture that is um uh noted by the arrow highlighted in yellow. Yep. Next slide, um This is case three again, just a few seconds uh to kind of work through the systematic approach to interpreting a text. 63. Yep. So next slide. Yep. So I got it. Um left pleural fusion. Um There are various signs that you can pick up when interpreting this. So the blunting or costophrenic angle um and the meniscus sign as well, um which is a crescent shape as shown in the image here. Um And of course, the basically the opacification is the main finding. Um Next slide again, just a few seconds for you to kind of work through the at approach and interrupt your chest X ray to know any abnormalities. OK. Next slide, please. So here there's um this is a case of multiple rib fractures. Um You can see that the fourth rib has um multiple rib fractures and then there's also a fracture of the third hip and 6th and 7th ribs as well. And another finding you can note in this chest X ray is that the um right hemodia is raised, uh which is secondary to reduced ventilation because of the pain the patient's going through. And I'll pass that on to my colleague. Now, we'll give you a bit more time to have a look at the images just so you've got a bit more of a chance and probably give you a few extra seconds, right? So, hi everyone. My name is Rao and uh yeah, Lag Nhan. Um I am gonna be talking about I uh chest X rays also Han I'm also an incoming F one. So yeah, um we can get, let's get cracking uh next slide, please. Perfect. So uh let's look at this chest X ray. Um and I will, I've given you a bit of a hint of what's going on. Um And it's literally written in the middle. So we're gonna compare the middle zone to this this chest X ray. And can anyone tell me what they think could be going on in this case? Yeah. So yeah, Jahidi has got it. Brilliant. Consolidation. Yeah. So um consoli perfect. I think loads of you have got it, which is brilliant, brilliant to hear. And yes, so Mohammed has suggested pneumonia. So consolidation is normally this wispy sort of pattern which we can see on the left side of the middle lung here and uh consolidation has various different causes. The most common cause that you find is always pneumonia. Um and it's always important to take the clinical picture into consideration. So, in this case, if a patient had high temperature and a productive cough, that would point towards a pneumonia which we can see in this case. Um it's also important to be aware of other causes. So, cancer, pulmonary hemorrhage and pulmonary edema, they are less common causes but something to be aware of, especially when you're considering consolidation. Um Can we go to the next site, please? Perfect. Um And now what about here? What can anyone notice Rupta viscous? Ok. Yeah. Yeah, there we go. The sur um Isabel Mohe loads of people who mentioned it. Yeah. So it's basically the pneumoperitoneum. Um So if you look at it, if you look at this, um, picture, what you'll find is the lungs, lung areas are completely normal. However, um, the there is a very clear definition of the diaphragm which we can see with the arrow markings and if we flick back and forth between the two, we can clearly see the outline of the bowel. And if you look quite carefully, you will note that the bowel wall, um, shows air on both sides which is indicative of wriggler sign, um, which you can see on the bowel on the right. It's hard to appreciate it once the line markings are once the like markings are already like labeled in this case. But if you flick back between the last slide and this slide, um, it's a lot more easy to see, um, the regular sign. Um And once again, always take account the clinical pa uh clinical picture. So in this case, the patient will present with abdominal pain guarding and normally they would have some risk factors. So use of nsaids or high alcohol intake um usually leading to a peptic ulcer. So yeah, in this case, um this is likely to be a duodenal ulcer which is perforated, causing this pneumoperitoneum which we can see um in this chest X ray. Perfect. Um And now moving on lovely. And what do we see? What do we think is going on here? That's quite a tricky one. There's quite a lot going on here. Yeah, he does mention heart failure. Yeah. And so has si S I'm sorry about it a name wrongly. Um and be also said, pulmonary edema, cardiomegaly brilliant like loads of people are pointing out cardiomegaly, pericardial effusion. Lovely. So there's loads going on and I think loads of you have pointed towards various things that are going on. And yeah, so this is a um a chest X ray of a patient who has had uh heart failure. So things to note when patients have heart failure, one of the most common things that they note that a lot of you have mentioned as well is cardiomegaly. And how do we measure if a patient has cardiomegaly? So the thing that we like to do is we measure the cardio cardiac ratio, which is how wide is the heart compared to the whole thorax ratio. And if that ratio is greater than 50% then we know that this is um cardio megaly. Now, the second thing to be aware of is upper zone vessel enlargement, which we can see in the big number one sort of circles here. And because we see these kind of patterns here, this again, I call a wispy pattern in this type of area. It's a sign of um upper upper the vessels being enlarged, which is normally indicative of pulmonary hypertension uh due to backlog due to the cardiac failure. What we can also see are these curly bee lines. Now, they're very hard to appreciate in this particular image here. However, I am going to go over the uh curly bee lines in the upcoming slides where you can appreciate them a little bit better. Next thing we notice is this airspace shadowing, which is this hazy pattern in um the middle of the lungs. Now, normally we see this um start to develop in the hilar regions which are normally ad uh hilar regions are just sort of adjacent. Yeah, where the just sort of towards the right of where the cursor is right now. And that's where you generally see um um airspace shadowing start to develop and then once and in this case, it's quite widespread. The last thing we notice is the blunting on the costophrenic angles. So normally the cost for angles should be quite clear and crisp, but in this case, um due to the pleural effusions, they're not clear at all. Um and once again, take into account the whole clinical picture. So patients who present with this kind of chest X ray would normally have poor exercise tolerance, um rapid onset shortness of breath, they might have a background of atrial fibrillation or uncontrolled hypertension. Um And that gives you a bit of a picture of what's going on. Um And right. Uh so yeah, let's move on to the next slide. So yeah, this is, as I, as I mentioned earlier, this is a side by side comparison of the image before and after the markings. So it's quite hard to appreciate the curly bee lines if you, but if you look quite carefully, we see these horizontal lines on the lung edge and that's what we really define as these curdy bee lines. So I mean, I don't know about you guys, but when I was in med school, um I just kind of knew curly bee lines were associated with heart failure, but no one really told me what exactly curly bee lines were. So this is like one way to like learn about what exactly curly bee lines are. So it's these horizontal lines that you see on the edge of the er lung, which we normally see called curly bee lines. Perfect and next slide lovely and then going into alveolar edema, which is some another aspect of heart failure. Now, this is very widespread um kind of airspace shadowing. Uh but it's this hazy appearance that you see throughout the lung and that's caused by fluid being built up in the alveoli due to the backlog due to the heart failure, essentially. Um And usually, as I previously mentioned, um alveolar edema generally starts in the hilar regions and is known as a battering distribution. But in this case, it's become quite generalized and you and you can see it um throughout the lungs in both sides. Um Yeah, next slide perfect. And we've got one more case over here. Anyone got an idea of what they think could be going on here. Give you a bit of time not to worry. Lovely. Oh my God. Lots of you have got this beautiful. Yeah, so it's standing out like a sore thumb. Oh my, it's got a a nail to a tee. So yeah, so loads of you have got this. Um We'll go on to our next slide. Yes, this is metastasis to the lung um from a renal cell carcinoma. So these, this is your typical cannon ball metastases, which um a lot of you have mentioned. And as you can see in this image, um there are metastases. So cannonballs of various different sizes, various different shapes. All of them have that general characteristic cannibal round appearance, which you can kind of see normally this is from a renal cell carcinoma. Um And um yeah, they're normally quite big and round and they're quite generally quite easy to note, quite hard to miss, but as of previously kind of banged on, like I keep trying to bang it or bang on about it and I'm sorry for saying it, but it's just also like, take into account the clinical picture. So in this case, the patient would generally present with the shortness of breath, weight loss. Um, they, you might have some sort of suspicion of malignancy. Um, so anyone who's presenting with symptoms that are indicative of likely of a malignancy or cancer or something like that. Um Then take that information into consideration when um when looking at an X ray like this as well. Um And yeah, I think if we move on to the next slide, that's me done. Um And yeah, I'm gonna hand it over to uh Mia who will continue our chest X ray series. Hi, thanks for who uh I'm Mira. I'm gonna to uh soon to be a teaching fellow and I'll be going through um a few more x-rays. And so this is our first x-ray. Um I'll just give you a bit of time to look at it and tell me what you think it is. All right. Excellent. I think I'm getting uh some correct answers. Um So this is um a case of uh tension pneumora, it's pretty clear. Uh The left side side of the chest uh is completely radial since you can't find any lung markings like the ones you have uh on the right. Um The the lung has collapsed. You can see it's just a very small radiopaque, uh collapsed lung here. And, uh you can see a little bit of um shift of the mediastinum to the right side and um depression of the hemidiaphragm on the left. It's basically, uh the longus called with the, the poor SCD was there. It's called the, the lung is collapsed and it's just the air is pushing everything away, um, from the left side of the lung. So that's why you see all sorts of uh these findings uh in a patient with te tension pneumothorax. Um uh you'd also find clinical findings like hypotension shock. The patient is very tachycardia, reas with venous pressure and of course, this is an emergency and it needs to be trained straight away. And so um next case, uh yeah, sorry. So this is uh the same for the same case. But on act, usually you would not do act for attention pneumothorax because it's an emergency and you have to drain it straight away. But it's just interesting to see again, uh collapsed lung uh at the bottom here and um air uh filling out the, the, the hemos. And uh you can also see some subcutaneous emphysema. This is something that you did not do not appreciate on the X ray. There's subcutaneous emphysema in, in the skin layers here. You can see uh some air which indicates that the reason for this pneumothorax is probably some trauma. So uh chest got traumatized, uh air got trapped in the skin layers, air went into uh pleura. And uh well, we cannot really see a rib fracture. Um This patient has a very high quality of having uh a rib fracture as well. Um So can we move on to the next slide? Yeah. So this is um our second case. Um Again, I'll give you uh give you some time to see what you think about it again. Yes. Um getting correct answers here. Um So, uh next slide, please. Uh This is as you can see here, um the upper lobe is completely collapsed, uh it's completely radio opaque. Um And it's very clear that it's, it's very different from the rest of the lung, isn't it? Um Sometimes it's difficult to distinguish between collapse and consolidation. Uh Here, it's pretty obvious because it's very, very opaque and consolidation would not be this opaque. But other signs that you can look out for is um the upward shifting of the horizontal fissure here. So basically, uh when it, when a part of the lung collas, it just pulls everything towards it. So that's why the horizontal fissure is shifted upwards. Uh Normally it would be more downwards than this also. Um The right side of the diaphragm could be also elevated. Basically because as I said, uh when a part of the lung collapses, it just, you know, you can imagine it pulling everything towards it So everything just moves upwards towards the collapsed lung. Um This is what it would look like on act. Uh So this is uh left up upper lobe collapse. Uh As you can see, this is the part of the lung that's collapsed, the rest of the lung looks pretty healthy on the CT and it, it looks very, pretty similar to what you can see on a chest X ray. OK. So, um this is uh another chest x-ray. Um I'd say this one is a bit unusual. Um not a very frequent finding, but I'll see if you can guys. Um If you guys can guess it. OK. All right. Um Just going from the chart for some reason. So I can't see the findings on this one, but uh said dextrocardia, dextrocardia, Hema peritoneum and someone said herniation induced diaphragm rupture, herniated bowel in the left hemithorax. OK. All right. Thank you. Uh Yeah. So this is um diaphragmatic rupture. Uh That is correct. Uh This is traumatic diaphragmatic rupture. So, basically, this patient had an accident, they had a trauma to the diaphragm, it ruptured. And the thing that you can see here on the left side, this is basically the stomach. So with herniated through the diaphragm uh into the sorex, as you can see, there's an air fluid level, this is basically the air fluid level of the stomach. And um so it kinda displaced everything that is normally in the left hemos sox that's why you can see a mediastinal shift uh towards the right. And uh again, the hemidiaphragm is much higher than the right because stomach just pushed it upwards. And uh of course, lung volume is much smaller here because uh stomach is just um pushing everything out of its way. And, um, this is a pretty unusual finding, but it is uh interesting to see. And uh next slide, this is the, this is act uh of what you would find in a dry metic hernia. Again, this is the stomach and lots of gas inside. Um And it's uh in the left team which works where it shouldn't be. Um And it's just interesting uh to see what it looks like on CT as well, but usually it's pretty obvious from a chest X ray. Um So I don't really need act. This is um my last slide here. Um This is a pediatric chest X ray and I'll see what you guys um say, OK. Yeah, this one, this one's um pretty, pretty easy cause there's a foreign body. Uh this the child, the child basically um inhaled the foreign body. It it looks like it's a nail. Uh So this is a foreign body aspiration. And um if we can move on to the next slide, please. Yeah. So this is foreign body aspiration. If uh one of you works on the pediatric boards, you might come upon stuff like this sometimes or in pediatric ed And so if the foreign body is big enough, it can obstruct the air, one of the airways, the bronchus. And it can, if it's a big uh bronchus, one of the main ones, it can cause a collapse of the whole, um, one side, 11 lung, potentially if it's big enough. So this is what happens here. There's a collapse, uh pretty much of most of the left lung. And, um, it's very, obviously, it's very different from the other side. Uh Also um well, that you can't really appreciate it here, but it can also cause depressed ipsilateral hemidiaphragm, which we can't really see here. But basically, this is a pediatric emergency and we have to get the foreign body out as soon as possible before it causes any more damage. And usually we do this um using bronchoscopy. Uh So next slide um This is, this is a bronchoscopy. This is foreign body that the child uh inhaled and this is how you get it out using a bronchoscope. This is an another chest X ray with another child who inhaled the foreign body as well. And yeah, the, that was my last slide. Um Thank you. I'm gonna hand over to um first of all, if we can go back to sharing. Perfect. Um So hi there. My name is I'm a medical and I'm starting I nt this August. Um So let's go to the first case, I'm just going to cover a bit of um NG tube x-rays. So I would, if you could just comment on the NG um whether it's in the correct position, uh whether it's not and what's going on. So I'll give you about 15 seconds. Mhm. Ok. Ok. Uh So um moving on to the next slide. So this is a, this is a normal tube. So what you need to look at while assessing the, while assessing? Ok. Yeah, a lot of people have said it's in the stomach, it's in the correct place. Yeah. So it should, it should descend down along the esophagus. Um Not go into any of the bronchi. It should bisect the carina. The carina is a bit difficult to appreciate here. But if you look um I think it is around the fifth, the fifth rib, it goes down, it passes the diaphragm and then crosses over to the left hand side. If you look at the bottom of the X ray, you can see the tip of the NG tube in the stomach. And as a rough rule, um the NG tube should go about 10 centimeters beyond the gastroesophageal junction. So that's about, that's a normal NG tube placement. So moving on to the next slide. So can you comment on this one? Is it in the correct position? Ok. Yeah. OK. Um Ignore the clips. No, no. OK. So moving on to the answer is it is it is in the esophagus. It, it has not gone down into the stomach. So we need to push it forward. Um, a good way to measure the length of the tube that you need to insert is from the bridge of, from the bridge of your nose to the yellow and down to the zip sternum. So if you, if you measure this before starting insertion of the tube, you will roughly end up about 10 centimeters beyond the stomach. So it's always good practice to do this. Um Next, next slide. No. OK. Can you, can you comment on the, on the NG tube? Give you about 20 seconds for the slide? I Yeah, absolutely. That's correct. It's it's not in the left lung. So this is another cervical X ray performed for the same patient. So if you see the NG tube is coiled up in the pharynx, it is not going down but outside, you cannot see the NG tube. So they send the patient down for the X ray. Um Obviously it was picked up and the NG tube was pulled back, pulled back out and reinserted into the correct position. So we make sure to check that it is not coiled up in the stomach. And if there is resistance, if the tube is not going, um it is obstructing somewhere, there shouldn't be pushing the tube down next slide. And this is my last case. So again, about um 30 seconds. No, no, no. Yeah. Yes. OK. Ok. Perfect. As um quite a few of you have correctly identified. The tube is not going into the stomach, it is going into the left lung. So if you look at it closely, it is descending, it is descending down, probably not in the esophagus. Um It bisects or, or it, it does not dissect the carina. If you can see where it is going to the left, that's approximately where the carina is. Um And it goes to the left hand side before the diaphragm. Um And then it goes down any, any other abnormalities you can see in this chest X ray. So there is a bit of pleural effusion on both sides, but there is some nemo thorax as well on the left apex and on the right, on the right side, the right upper lobe. So it probably could have happened because of the trauma while inserting the tube. We don't know. But the learning points here are just to just to be careful that just because it is descended, it is going towards the left hand side does not mean um that this is in the correct place. So trace the tube correctly or appropriately right from the start to the end to make sure the tip is in the stomach. It descends along the um esophagus bisects, the carina goes down, the esophagus goes down the diaphragm and then goes to the left hand side. Um And I think that is all for me. Thank you. Good evening guys. I'm Dan. I'm one of the class at Jos the West Middlesex. Um Bilal couldn't be here right now. Oh no, he can. Yeah, perfect. I'll leave you. Thank you. Uh So yeah. Uh we have divided the abdominal ex Yeah, first I'll introduce myself and um I'm working in the emergency department in Peter Hospital. So we have, we have divided, am I audible? I'm not sure. Hello? Perfect. We can hear you below. Yeah, thank you. So, so is that Dan and I uh we have divided this, I will just quickly run through the approach to abdominal x rays and he will run through a sample and show a test on the previous knowledge. So, um abnormal x-rays, you might see a lot, lots of approach on different um websites, but I think I saw it on uh on me the BBC approach to uh abdominal x-rays and I think it simplifies a lot. So what it stands for is BBC, uh bowel bone and calcifications. So, uh first we look at the bowel, especially in the emergencies, we look at bowel and other organs, especially the bowel, small bowel and large bowel. So usually the bowel, we have two abnormalities. One is obstruction, other is perforation. So, uh I won't be going into the specifics of these x rays because Dan has a special graze for this. So, uh in small bowl obstruction usually do what happens is uh first you will see the dilated bowl and you would see, uh, for dilated bowl, we have 369 rule, which is, uh, you have uh three centimeters for small bowl, six centimeters for a large bowl and nine centimeters for uh cum. And if it's dilated, beyond that, we see it's dilated bone and in small bowel obstruction, the dilated bone is usually towards the center of the abdomin x-ray. While as in large bone obstruction, it will be towards the periphery. And here in small bone obstruction, you will see these mucous fs con or connivens that they, they will run through the entire length of the bone. So these straight lines, we are showing they'll run through the entire length of the bowel. And if we do an uh ect x-ray, you will also see ear fluid levels in small bowel obstruction. And you will see multiple uh air fluid levels on the right side of this uh on the right um uh ex abdominal x-ray, multiple air fluid levels, this air and fluid levels, which is um you, you also see dilated bowl as well in this next slide. So this is a, a large ball of two reasons. One, it's a dilated bowl and that uh the dilated bowl is situated towards the periphery of the abdomen. It's not in the center, it's usually towards the periphery of the abdomen. That's where the large b uh A large b usually lies. And uh you can see a major difference which is these indentations in the small, in case of small b obstruction there and throughout the length of the bone. And here, uh you'll see these indentations or the host, they do not, they are just just indentations in the wall. Uh That's how it appears in the X ray. Uh puke in obstruction, you might also see a regular sign, but that will explain, he has a, a separate x-ray for that Nick sl. So again, the head of, of the we have uh seen have will identify obstruction of there is sometimes appropriation occurs. And in case of per most likely we'll see uh uh air gas under the diaphragm as we've seen in the past few slides. Uh The 1st 1st couple of speakers talked about it and it's very clear in the right side to blo the right he diaphragm and as well as in the left uh left he diaphragm. I'm sorry. Uh We will see regular sign in perforation and I'll explain that that's not present in the obstruction. Yeah. Next slide. So, in the bones window, you'll see uh uh mostly we do abdominal x rays for uh because we don't usually do xx rays for bones, abdomal x-rays or bones. Mostly we'll do it for bowel obstruction and perforation. But just for a quick look, we can see that there is sclerotic patch in the entire length of this bone in the tubular and in the femur as well, it's probably uh disseminated mets uh from some malignancy next slide. Yeah. Again. So in the uh to conclude that the BBC, it's um bowel and then bones and then calcification, you, you can, you can, you can uh look at the calcifications in the upper left corner of this. There's a staghorn calculus present in the kidney, but sometimes it's not as obvious as this. Sometimes it could be just minor calcification present and you could identify a kidney stone. You could also identify maybe other calcifications. But yeah, that's it for next slide. So, thank you very much bal. Um It's my turn. Now, I'm done on one of the third classic shows at West Middlesex and I am essentially going to be going through some surgical case studies. Uh Obviously, there are loads of pneumonics just to try and use whichever one, you know, whether it's A B CBBC or something else and just apply it to these, these cases really. So we've got case number one and you've got a 42 year old smoker also drinks excessively. Uh And he's also sprained his ankle recently. He's on Ibuprofen and he's had worsening abdominal pain over the last four days and this is his erect chest x ray. Um Most of these, most of these chest x rays or, or abnormal x-rays too. You, you've seen the pathology on them already. So hopefully you'll be able to get it. Ok. Yeah, I'll give you a few seconds, a few more seconds to have a look and have a go. Let me know what you think. It is. Very good. Well done guys. So, um I've got three correct answers. So if we go on to the answer, we've got Neo Peritoneum and um you air under the diaphragm, the same thing and perforation being the root cause in most cases. So, um well done guys perforated hollow viscous if we just go back to that slide fall. So, yeah, perforated hollow viscous being your main root cause, um, causing the air. The free air common pitfalls I think is quite worth going over. So recent surgery or instrumentation could cause free air and a small amount certainly of free air. So that's worth thinking about and, um, worth thinking about including your in, in your clinical information. If you are going to request one of these, um, or the gastric bubble can sometimes be quite big and look like neo peritoneum on the left side or if you have a bowel obstruction and you've only got the bottom, you can only see the bottom and it's interposed with the, the diaphragm. So it looks like neop peritoneum. So it's just worth being sure before you commit to that free air under the diaphragm. Great. Next slide, please. And we've already talked about regular sign. So this, uh, this single bowel wall with free air outside the bowel and intraluminal air, um, forming this barrier that these areas are, um, pointing to usually seen in cases of significant free air so large holo viscous perforation. It slow, please. Another case of a 67 year old female who's had previous abdominal surgery. I think we might have even you've seen this slide before, uh, and, and progressive abdominal pain and distension over the last couple of days. What do you think guys? Yeah, kind of answers so far. That are correct. So, if we go on to the next slide, we have small bowel obstruction. So we've, we've definitely seen a similar, um Abdo film to this already. Uh We can see we've talked about 369 rules. So we've got dilated loops of bowel and they've got the lines that run the whole way across the valvula contes, which denotes these are small bowel um throughout the abdomen. And, uh we, I talked about that previous abdominal surgery, ascertaining to the fact that it might be adhesional. We've got some common causes there that you may see on an Abdo film if they're, if they're significant, but just having this Abdo film would, would direct you to further imaging, which is the main thing really. Um So next slide case three, a 40 year old female who's had colicky, right upper quadrant pain for a few months and now has presented with worsening abdominal pain and distension of the last few days. So, if we could think about the main thing on this, give you a little bit of time to look through it. It's, it's, it's linked the last case. So if, if you can just maybe tell me about, yeah, tell me about what's on there and then we can maybe go through it afterwards. What you think? Yeah. So we've got constipation and we've got small bowel obstruction. So far we've got gallstones, which is a good guess. I like the thinking anyone else. But almost if we put the two together, then we pretty much get there. So we go to the next slide. So I've got something slightly different. So I've got gallstone ili. So in a similar way to the last, um, the last case, we have dilated loops of bowel, they look like small bowel cos I can see some bowel var contis. And if you look down in the pelvis, you can see an ovoid calcification or calcified density, which I hope I convince you in the case of this lady with Colicky, like quadrant pain is a gallstone. So you might be able to pick something like a real significant diagnosis. In some cases you can also see in the right up quadrant Neilia. So you can see some air in the bilary tree quite hard to see. But I think you can see it up on the right upper quadrant just above the highest loop of dilated bowel. Um, but yes, that's an interesting a film if you can go to the next slide. So case for 72 year old male who's had some new neurological symptoms and seeing his GP for investigation has come in with abdominal pain and distension over the last couple of days. Bowels not opening. Uh If you can maybe describe what you can see or a sign or whatever you think. Yeah. Very good guys. Very good. So we've got some descriptions and a sign. So we've got perfect. Um Let's go to the next slide. It's got sigmoid volvulus. So as some of you have written, we've got the coffee bean sign. So it the sigmoid colon twisting on its Mery usually have a large redundant segment of sigmoid colon twisting in the left iliac fossa and then the two significantly dilated loops of large bowel interpose with that thickened wall in the middle um forming our coffee bean sign. Very good guys. And I think I'll Oh yeah, I've included this. Yeah, yeah. Next slide, please. Um So this again is if you were to CT, which often they will progress to a CT scan to determine the, the whether there's any ischemia on the scan. Um So again, we can see the coffee bean sign quite nicely on the CT demonstrated. And the last case, I believe he's a 60 year old smoker, a male who's had gone back to chest X ray. So a sudden onset tearing, central chest pain. Uh again, if you could describe anything, you can see any abnormalities or, or even the diagnosis that would be great. Give you a bit of time to look through it. Ok? Yes, it's a bit tricky. This one. There we go. Oh, thank it. Yeah, very good guys. Very good. So uh we have a widened meter sinum which I hope I can convince you of er so n above eight centimeters when the patient's supine or above six centimeters when they're at are the higher end of normal. Uh and the causes, as somebody as venous already mentioned, I believe uh one of the main causes is aortic distension in the context of trauma tends to be um traumatic aortic injury or main vessel injury. Um So you tend to see this measurement, this the superior meters tends to be either obviously over eight or over six centimeters and you'll tend to see particularly in large ongoing bleeds, features of volume gain similar to when you'd have any other expansive process in the mediastinum. So, increased spacing between the ribs. Um You'd have uh tracheal deviation if it's on one side or the other, you might have depression of the left or the right main bronchus tends to be the left if it's aortic. Uh and there are other assaulted features that you might see particularly in former things like pneumothorax or hemothorax. Um So, yeah, well done guys, I believe that's the end of mine. Oh, no, a bit more. Yeah. So this is another one with a more maybe more significant findings just demonstrating what we've talked about there. So you can see the um particularly the left side, the aortic contour is quite abnormal. And we have some of those features of volume gain, particularly on the left side and also a large left side is hemothorax. So I think that's everything for me. Yes, thanks guys. Thanks. Uh Daniel. I'm hi guys. I'm so I'm gonna be talking through some CTA cases uh just an incoming for. Um So yeah, first case. Um So this patient presents with a sudden onset headache, severe pain located in the occipital. Any ideas about what this could potentially be? So, yeah, so we've got some answers there. Uh Correct. So, subarachnoid hemorrhage. So next slide. Yeah, you got the answer there. So yeah. So subarachnoid hemorrhage typically presents with kind of a thunderclap headache, sudden onset, sometimes patients can be photophobic, they could have loss of consciousness and typically your causes are um trauma and aneurysms and you can get some risk factors of a family history, high BP, heavy alcohol consumption and then some like abnormal connective tissue disorders. So with the aneurysms, things like um uh a Polycystic kidney disease can, can have some incidence of very aneurysms which can cause that as well. So, yeah, you can see the blood, I'm sure you can see the blood there in the, in the systems, the hyperdense region. It kind of appears like a star and then sometimes uh you can see some blood in the, in the fourth ventricle as well. Um So next slide. So case two, the patient presents with uh struck by a baseball bat on the side of the head and the patient has also vomited twice and you get this CT scan here. What do you guys think this could be? So, yeah, we've got 11 there already. So, yeah, I think s meaning extradural hematoma. So here you have a right sided extradural hematoma. Um So which is a collection of blood uh between sort of the inner surface of the skull and the dura mater, but outside the dura. Um and because it can't cross the suture lines, it's kind of in a compact space. And then you can see here that that kind of leads to increased intracranial pressure and you get a bit of a midline shift there and if it gets so severe, it can cause um herniation as well. So, these are a matter of urgency to, to kind of treat usually with uh craniotomy to evacuate uh the clot or the bur hole as well to relieve some pressure. So patients typically can present with uh loss, may, may or may not present with a loss of consciousness, severe headache and sometimes can have a lucid interval um after injury. Um um So yeah, and usually the soft spot around the pterion where kind of some of the suture lines meet. Uh Is it the hematoma is usually caused due to, to trauma to the area where the middle meningeal artery lies and that rupture cau causes this this bleeding. Um Most typically. Um So yeah, uh next slide place. So case three, patient presents confused and drowsy after a fall, they have a past medical history of alcohol misuse. What can you go see on the CT scan here? Yeah. So we've got that. So you can see that sort of cresentic lesion um on, on the patient there, on the left side. Um And because of the kind of appearance of that um lesion, would you say that that would be acute or chronic? Anyone have any ideas? Yeah. So because it's um it's not as showing up as bright. So it's hypodense, we would think that this would be more of a chronic uh subdue rather than an acute in the acute phase. Um the blood can appear more brighter on CT scan and then after the blood sort of breaks down, it becomes hypodense. So it's thought to be due to kind of tearing due to that trauma of the uh bridging veins. Um So those, those kind of cause the bleed uh bleed there. It can kind of happen in young infants who via like non non accidental injury. Um young adults with sort of trauma and motor vehicle accidents and then elderly typically for falls or um patients with alcohol issues also coming in with falls can, can have sort uh sometimes can have chronic suffers leading to presentation of their symptoms. So yeah, next slide please. So yeah, a patient appears confused um with an abnormal gait. What do you think is going on on the CT scan? Yeah, so said the normal pressure hydrocephalus and you can see. So it goes to the next side, you can just see the ventricular ventricular megaly. And this is, yeah, as you guys mentioned, normal normal pressure hydrocephalus. So patients can typically present with kind of three main features of urinary, incontinence, cognitive impairment and gait disturbances. Some people kind of use the mnemonic we wacky and wobbly to kind of remember that. So you can kind of. So it's typically patients who are elderly and they're not quite sure as to why normal pressure hydrocephalus occurred, but it's thought to be due to um ineffective uh cerebral spinal fluid reabsorption leading to a build up of of CSF fluid. Um So, so that's, that's there ventricul and that's on my chest. There we go. Uh Hi. So I'll be presenting on low lymph fractures, but I don't think I'll be able to see the chat at the same time. Is that true? I can discuss the chat findings with you as we go, right? Ok. Then I'll start. Um So hi, all my name is Seb I'm ac one in Ent working at Newcastle upon Tyne hospitals. So let's move on. So the first case uh uh the lower limb fractures as we know before I start that we know we have pelvic fractures. We have uh fe uh femoral fractures, uh knee fractures, ankle and foot fractures. So, uh the first uh case is about a motorbike accident in a male, 55 years of age. This one is a bit tricky, but I thought it's worth discussing. So this is an x-ray and if anybody could comment on the x-ray, any answers, no answers. So far, someone said superior pubic rami fracture on the right. So yeah, that is partially true, superior pubic rami fracture. There are other fractures as well. So in total, there are three fractures and they, I can give a hint that it just affects one part of the pelvis. So if you could just compare both the uh sides, I think uh it'll be a bit more like the superior pubic rami fracture. Uh I think there is also a inferior pubic rem remi fracture. And if we could just go a bit way upwards uh and trace the sacral foramina, I think we could appreciate on the same side of the pubic uh fractures, we could appreciate uh a bit of loss in the continuity on the sacral foramina again, which is consistent with the fracture. I understand this was not a very straightforward. So I'll move on with it. So if you could clearly see the arrows here, the white one and the two yellow fractures superior and the p inferior pubic rim eye and the upper fracture affecting the sacrum. So this fracture has got a fancy name and it's called a Malign fracture and it is after the person who named it. So this fracture is uh usually uh affects uh one part of the pelvis and it is a unstable type of fracture. And most of the time the mechanism of injury is a vertical she energy vector following an RT or uh fall from height. One sure uh subtle sign would be uh this kind of vertical energy vectors can come into play for somebody riding a motorbike. So these are more commonly seen in motorbike accidents rather than on a 44 whe vehicle. So I think this is one thing and also fall from a height would uh generate that vertical fact uh energy vector. So clinically the presents with shortening leg on the affected side. So combining the medical uh uh the clinical presentation with the X ray findings, we can diagnose it as a mal fracture. And in terms of the treatments after initial resuscitation, we do a open reduction and internal fixation, which is a definitive management. So let's move on to the next one. Uh This is a fall uh at work for a 45 year male who presents with pain, swelling, knee and deformity and a pretty straightforward x-ray if anybody could comment on. So patella fracture has been said a couple of times. Yeah, exactly. Absolutely. This is a typical case and it's one of the most common knee injury, which is a patella fracture, which is very uh obvious and uh mechanism of injury. Again, it's post direct trauma to the patella or uh sudden forceful contraction of the cords muscle, which is always in context of a sports injury. Patient presents with a marked swelling and pain over the patella with and with point tenderness and reduction in the extension strength. Usually there is a large joint effusion or hemarthrosis uh over the affected uh patella. And again, in terms of treatment, it uh as with any fractures, I think the general rule is non displaced and displaced fractures. If the fracture is not displaced, we could go by non surgical ways uh by splint cast or anything of that sort. Same ways here in a patella fracture which is non displaced, we can give, give us a Zimmer knee splint for around 4 to 6 weeks and the patient would be usually weight bearing. But if it is something like a displaced patellar fracture, we need to go towards the surgical side and we do AK wire technique. This again is a very common knee injury. Uh So yeah, this was straightforward. Next is uh a, a female uh 35 years of age following a recent trauma to the right foot. This is one is the frontal uh x-ray that I have put up and right next to it. Uh an oblique x-ray uh if you could just uh in terms of these kinds of fractures, I feel if you divide, seeing the phalanges, then uh proximal distal phalanges, then metatarsal and tarsal bones. If we kind of go through them, we can appreciate a fracture somewhere. Uh I think that's the best way to do. Uh And to get the answer quick, I would uh suggest going on the oblique phlegm and uh focusing on it because this is not really the frontal one doesn't really give us that answer. So we could see on the oblique x-ray. Uh And maybe if anybody could point out nothing in the chat so far, I see. So, so if you could see the distal Phalens, proximal phalanges of this. And uh if we go to the uh fourth uh PHX, if you can see here closely, we can appreciate a fracture here, which is quite settled. But again, the history would be very convincing because there would be very gross swelling and pain in that part. This is an X ray of again, a non displaced extra articular fracture at the base of proximal pings. And it's for the fourth toe. Again, mechanism of injury is a direct injury to upper part of the foot and presents as with any fracture, pain, swelling over the fourth PHX. And again, with regards to the treatment displaced and undisplaced fracture. If it is not displaced, then this protocol which we use for the sprains, ankle sprains or anything, the rice protocol, which we famously call the pneumonic rest ice and elevation of foot. That's the conservative management along with splinting and taping the injured toe to the adjacent toe or by using some support boots for around 2 to 4 weeks. This is same with the fingers as well. If one of the finger is broken, we kind of splint or tape it to the adjacent one to immobilize it and then repeat an x-ray after four weeks to see if that's healed. Uh, that's for the undisplaced fracture. If it is a displaced one again, would need a reduction. So that is about it. Next one is, um, medical and a surgical emergency maybe. So, this is a case of a 55 year old male who presents with poor control of diabetes. Sorry, the spelling is wrong following a recent trauma. So, uh, if anybody could comment here on the frontal x-ray, we could see some findings and maybe to the bones as well or of the ankle, we could appreciate some things. So if we go on, uh, anybody, any guesses, no, give a few more seconds and see if we get anyone in the chat, right? Ok. Got osteomyelitis. Charcot's deformity and osteitis of the distal phalanx of the great toe. Yeah, absolutely. That is, uh, one correct answer, but we also have another finding here way down. Um, but osteomyelitis, uh obviously with accompanied soft tissue swelling is a wonderful answer. As well. Um Yeah. So as I pointed out clearly, this is the osteomyelitis affecting of the affecting the first two. And then here, if you see the bones down, we see a navicular bone fracture as well. So uh this X ray uh as uh pointed out clearly shows a osteitic lesion in the distal phx of the first toe. And we can definitely see the soft tissue edema around it, which is highly suggestive of osteomyelitis. And in addition, if we go way down, we see a avulsion fracture, which is noted in the medial aspect of navicular bone, again accompanied by a soft tissue swelling. Clinically, the affected food will be like uh in any case of osteomyelitis, very hot tender along with swelling e erythema and uh uh highly consistent of osteomyelitis. Management wise, focus is on the osteomyelitis. Uh resuscitate the patient give uh a high dose intravenous antibiotics and, and for the bone, if, if the bone is damaged, then we debride the bone, but that's all about it. So I think I'm done. Yeah, I think we'll move on to the next presenter. Is it? OK. Yeah. OK. Thank you, sir. Uh So I'm I'm in Liverpool and presenting the common pli bone fracture. So, can I just move to the next one? Yeah. OK. So this is the first case treat it straightforward. The presentation is small while ta in a four years old, baby girl. Yeah. Four years old girl. Yeah. Any gas, anyone, it's pretty straightforward. Yeah. So the time, yeah, let me just check. Yeah. Absolutely. Right. It's a green stick fracture. So that's a very common fracture in Children. Very common, uh, under 10 years old. Uh, and the main mechanism of injury is like an angulated force that's caused one of one side of the cortex of the bone to bend, become convex and there is a bridge on the cortical bridge in one side. So it's an incomplete fracture. And treatment is variable depending on the age. Usually four weeks cost and less than 10 years. If more than 10 years, then usually five weeks cost. So can you just move to the next side, please? So here as a case, very common fracture in Children. Can anyone appreciate the fracture here? And I'm just going to give some time to get some response. Anyone can appreciate the fracture here? Ok. So can I just move to the next one? So this this is called a buckle fracture of the distal radius and ulnar. If you see the fracture, you cannot see any distinct fracture line here. This kind of fracture is just because of the trabecular compression because of the loading. So the cortex become buckled over the trabecular bone. So that's why you can just uh notice a bit of like irregularity on the upper end of the sorry, the the deterrent of the radius. So this is very common uh buccal fracture. It is called a circumfer bal fracture. Another name is torus fracture as well. Uh Sometimes you cannot see anything but if you, you clinically suspect that something is wrong, the patient has symptoms, then you can just have a follow up X ray as well. Usually it's left untreated like this because it's self resolving, but sometimes they need the cast for immobilization. Can you just move to the next slide, please? So here is another fracture. The presentation is a young child no longer weight bearing. Uh age is toddler age. OK. Can anyone s and how, what is this? So the hint is that there's a very subtle fracture. OK. You have got one response. Let me just see exactly venous, the distant tibial fracture. So here, yes. So there is a very subtle and displaced spiral fracture of the tibia which is very, very common in toddler. It's called a toddler fracture. So there is a name for this, which is called cast fracture. Childhood accidental spiral tibial fracture. So it's in the tibia. The spinal fractures in the tibia is very common when the you know toddler because the mechanism of mechanism of injury is like the first internal rotation when the ankle and the foot is fixed. But if the spinal fracture is in the femur femoral bone, the femoral spinal fracture, it's not a toddler fracture. It should raise the suspicion of non accidental injury because it's very uncommon in uh to have like a spiral femoral fracture in toddler. Can I just move to the next case, please? Yeah, this is the last case. So the presentation is fell off on the ladder, fell off the ladder in jungle genes from height of 1.5 m. Now, the 16 months old baby is not moving the right arm anymore. So here there are three fractures basically. Can anyone tell me just what are the fractures? Yes, we have got some answers. Anyone else? OK. Yes. Can you just move to the next slide, please? So here there are three fractures basically. So there is a buccal fracture in the distal end of the radius. That's right. And there is a sh shaft fracture in the uh mid mid sha oblique fracture in the radius as well. And there is another bone fracture which is actually not a fra uh like prostate bone, which is also an incomplete fracture. It's considered as incomplete fracture in Children of the ulnar. If you see the ulnar has like been a bit bowed. So uh can you tell me just uh what, what is has anything stop in your mind uh from the history? What could be the case? Yeah. OK. Exactly. Uh It's a a case of non accidental injury basically because 16 months old baby, it's very, very unlikely to fall off from the ladder 1.5 m ladder. Uh So and multiple fracture as well. So which is very common in non uh accidental injury. That's it. So that's why this, thank you so much. Thank you everyone for joining us today. And it's been a variety of cases and some repetition, which is always useful just to get some of the more common imaging findings. If anyone's got any questions, pop it in the chat over the next couple of minutes and then we'll try and answer them for you. In the meantime, we've got the feedback link which has just been sent. It'll be really, really helpful. We've had lots of different speakers, but it would be really great to hear what you found use for what we can do to improve. If you like the quiz format that we can have or if you put it in a different format, that would be really great feedback. And then I'm just gonna send another link in the chat that WP MN are recruiting at the moment. There's lots of positions available. So I've got the Google Doc link, but you can go onto Instagram on all our social media pages to find out a bit more. And on that link, it also breaks down the job description for all the different roles as well. So I'll stay on the line for a little bit longer just to see if there's any last minute questions or anything about interventional radiology. I'm also happy to answer, but thank you very much to all our speakers today. I didn't have to do any work because they all did a great job with their presentations and putting it together. So, thank you very much. Thanks. Said I've seen it in double cos you're still sharing your screen. So it was like double, good job to everyone. Thank you. Have a great time. Ok, I don't think there's any questions. So we'll close this talk. Thank you everyone again and see you at our next event. Thank you. Thanks a lot. Thank you.