MSK MRI: Incidental Colorectal Carcinoma – Probably

one of the drawbacks of the current job is that I rarely get feedback on cases and there are plenty of good cases. This was done for hip pathology but given the appearance of the sigmoid colon, I would place a greater than 70% probability that colorectal carcinoma is present which is probably asymptomatic.

In cases like these I typically recommend CT abdomen and pelvis with contrast and colonoscopy. In this case in particular, the CT will help assess the morphology of the hip which was the primary cause for obtaining the study.

Could it be diverticulitis or IBD?  Sure. Would I want to assume such and more importantly…

Would I want that section of colon in my pelvis?  — >

— >   Absolutely Not



TD Ameritrade Commission Free ETF Shenanigans Continue

Nowadays, the saying “put his/her/their foot in their mouth” is more appropriate than ever.  If they put their hand in their mouth, then they couldn’t keep making things worse, because hopefully they could no longer type (barring a Daniel Day Lewis “My Left Foot” kind of phenomenon).

TD adds another steaming pile of excrement to their already formidable accumulation of ETF Egesta (yes, I looked that one up and am loving it).   I was going to use the word “Shisno” but that is even more fringe.  LINK : SHISNO Def: Shisno’s are considered almost universally repulsive, partly due to the fact that their excrement produces its own excrement following initial defecation. It is most commonly used as a racial slur for humans, demonstrating the animosity of the two species.


So now you have even more ETF’s to mismanage.  Data has shown that the more choices an individual investor is offered, the less able they are to make appropriate decisions about how to invest.  It’s much like choosing mint chocolate chip ice cream. If there is only one choice, it is a binary decision.  Choose or walk away.

But lets say they have:

  • Mint White Chocolate Chip
  • Mint Conflict-free Chocolate Chip
  • Mint White Chocolate Chip
  • Mint Dark Chocolate Chip
  • Mint Swiss Chocolate Chip
  • Mint Belgian Chocolate Chip
  • Creme de Menthe Chocolate Chip

Now I’m stymied by the choices.  In reality, they probably all taste the same. I’ll walk away feeling satisfied after ingesting only half a pint.  You know this is fiction because…



So the current timeline is: Take away good ETFs from commission free list, then extend the window to cash out, and now give even more crappy choices.  All cleverly disguised under the banner of enhancement.

I’ve clipped the best of the lot, the SPDR’s which STILL don’t include SPY. In fairness, it includes the less liquid SPY relatives.



Ankylosing Spondylitis

This is one of those classic appearances of the bamboo spine associated with ankylosing spondylitis. Also note the ankylosis of the sacroiliac joints.

Always be aware that these patients are predisposed to pathologic fractures that are atypical, mostly going through the disc space and then continuing on into the posterior elements which are typically also fused. Despite the column theory, many of these are unstable because there is no ligamentous support.

As Dr. Tom Harle used to say:

“just get a CT”

That man was beyond compare and could diagnose traumatic nerve root avulsions and pseudomeningoceles on a single AP chest film.


I have taken off the infinite loop because I am switching to image magic to process the gifts rather than an online methodology. If you have a preference one way or the other, let me know in the comment section below. I greatly prefer a few loops with static images of pertinent findings over infinite loops which could be found on the bad HTML website.


Rectus Tear into adductor aponeurosis and tear of adductor origin

The following in my own opinion and should not be construed as a factual statement:

First things first…Sports hernia is an idiotic name.  I think the general surgeons came up with this so they could stop infecting mesh on patients and operate on young people.  The person who thought this up should be shot.

Uncommon injury but important

Patient fell in a hole and wrenched his back. Presented primarily because of hip pain. The ER physician was persistent in the workup and after a negative CT chose to pursue MR which was the appropriate test in the circumstance.

This is an unusual injury, particularly in the setting of minor trauma. This Constellation of injuries, particularly involving the adductor aponeurosis is probably more regularly seen in conjunction with unstable pelvic fractures with rotatory instability.



VA and HSA

VA Medical Benfits and HSA

Since leaving my last job and becoming a 1099 contractor, I have returned to the VA system as a veteran with a service connected disability rating.  The biggest bummer about not having to have insurance was the potential loss of an HSA contribution.

HSA contributions are the triple tax free gift from the government to anyone, but most potent for earners who are phased out of other plans.

From IRS:

A-5.  An otherwise eligible individual who is eligible to receive VA medical benefits, but who has not actually received such benefits during the preceding three months, is an eligible individual under section 223(c)(1). An individual is not eligible to make HSA contributions for any month, however, if the individual has received medical benefits from the VA at any time during the previous three months.

So, as long as you have not received care in the previous 3 months, you can make a full annual contribution to your HSA without penalty.  This is great for healthy people.

The other option under consideration was going with the cheapest HDHP to enable the HSA, however the cost of HDHP would likely overcome any potential savings of the HSA.