Two Cases of AKI : Presumed Rhabdomyolysis in Military Patients

2 patients on 2 consecutive nights from a Naval Medical Center.

Both were stone studies, which was a reasonable clinical suspicion since that is probably the most common cause of flank pain. Both of them also presented with elevated creatinine precluding contrast out of concern for contrast nephropathy.

As an aside, acetylcysteine has no protective effects on the kidneys in the prevention of contrast induced nephropathy. I do not know of any institutions who were actually using this on a regular basis but from time to time it pops back up as a prophylactic measure in CIN. This was recently commented on in up-to-date.

What made me notice this “pattern” if you will, was that perinephric stranding is fairly uncommon in the young military population in the absence of chronic disease or urolithiasis. On seeing the 2nd case on a consecutive night, I did some digging to find out whether the previous case was actually the night before and from the same institution. The biggest concern in my mind was whether there was an epidemiologic issue such as HUS-TTP.

My suspicion is that it turns out it is an epidemiologic issue but unrelated to infection. Both patients reported to the emergency department with flank pain and no trauma after vigorous physical training (PT) workouts. They did have hematuria. Creatinine was above 2.0 in both patients. Although CT is unreliable, they both seemed adequately hydrated (IVC distention).

I would love to hear follow-up on these cases as it seems that this is probably rhabdomyolysis with acute renal injury secondary to vigorous exercise. I cannot remember seeing such a close association however the most likely thing is that this happens often and I simply miss it because the patients are not imaged or other people take up the studies.

For me it is a reminder that military training is not a benign process. To create the outstanding fighting force, young men and women not only sacrifice the best years of their life, they endure physical and psychological hardship for the benefit of the homeland.

 

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Quadriceps Tendon Rupture

I have commented in the past that I read for several military hospitals as a part of teleradiology. In general, the physicians at these military hospitals appear far more judicious than other hospitals I have worked for (Moses Cone Hospital) in their use of imaging, particularly “high-end imaging”.

Private physicians have a low threshold for ordering advanced imaging which seems to be out of fear of litigation or patient demand. Regardless, this is a degradation of the physician’s fiduciary responsibility to the patient. This is an unfortunate reality of modern medicine. Unfortunately, this leads to greater expense and does not improve the quality of healthcare overall. This has been well demonstrated epidemiologically.

This is probably an effect of decreased threat of litigation and less practicing of defensive medicine than is seen in the civilian sector. This is a great example of appropriate use of imaging by a beleaguered overworked ER physician. The patient had compelling findings on the exam and was sent for MRI for orthopedic evaluation.

 

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Although the amount of retraction is mild at the quadriceps tendon rupture, this is appropriate use of imaging because the sooner the tendon is repaired, the less retraction the surgeon has to deal with. With this workup in the night, the orthopedic surgeons can repair the tendon early the next day provided operating room space is available.

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It makes me think that practicing medicine with the military is probably the closest the United States will ever come to a reasonable decision-making practice model and mitigate the effects of defensive medicine.

Sternal Fracture and Chance Fracture

Sternal fractures can be frustrating to find, because they are frequently inapparent on the most commonly used image set, axial images, but are smack you in the face obvious on the reconstructed images. This unfortunate patient has a series of very bad injuries, the sternal fracture is the least of which. I am posting this case just to demonstrate how subtle the findings can be on axial images when they are so obvious on reconstructions. It still boggles my mind that places do not do sagittal and coronal reconstructed images on every single case.

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And now for Mr. Obvious

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The more subtle finding on the sagittal image above is the chance fracture of T11 just below my hideously bright banner.

 

And here is a great look at the split pedicles.

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

 

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.

 

 

Scapholunate Tear

Patient with popping imaged several months after the initial injury.  I’ve been told by the one of the best doctors I’ve ever met that it’s the dorsal 4 mm that contribute almost all of the structural stability to the wrist. That doc is Bill Gramig, MD at Greensboro Orthopedics.

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Further, the malalignment that occurs with a tear of the scapholunate ligament is thought to be due to torsional rigidity of the wrist; that is to say that the wrist is “sprung” when the ligaments are intact and with a tear of the ligament, the stability of the proximal row becomes disrupted leading to an “unsprung” wrist and ligamentous DISI.

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The DISI was not as “slap you in the face” as I like to see it on MR so I waffled a tiny bit, even though I was sure it was present radiographically.  Even though these lateral images are oblique, this is an example of smack you in the face DISI.

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