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LearningRadiologyByWilliamHerring,MD,WilliamHerring博士制作的播客整理而成的。WilliamHerring博士是 e Podcast1:The5RadiographicDensitieson [0:15.8]I’mWilliamHerringfromAlbertEinsteinMedicalCenterin[0:20.3]Sothe5basicdensitiesareimportantforourfundamentalunderstandingofconventional[0:27.9]Theyhelpusto lthelocationofthediseaseandtheyalsowillhelpusto lwhatthosediseasesmaybe.[0:34.6]Thefivedensitiesaremetaldensity,boneorcalcium[0:39.6]softtissueorfluiddensity,fatand[0:43.7]Andthegraphiconthe indicatesapproximayhowthey'llappearona(n)[0:52.0]Metalabsorbsthemostx-rays,andveryfewofthemreachthefilm[1:01.0]Air,ontheotherhand,absorbstheleastX-[1:04.0]So,mostwillreachthefilmcassetteandbeabletodarken[1:09.2]Calcium,fluidandfataresomewherein[1:12.2]Sosomeareabsorbed,someare[1:15.2]Andtheyproducevaryingdensitiesonthefilm[1:20.8]Howthisworksineverydaypracticeisshownonthisfrontalchest[1:26.4]Wecanseeairdensity,hereinleftupperlobeofthe[1:32.4](We)canalsoseeairdensityintheroomsurroundingthe[1:38.1]Wecanseefatdensityinthechest[1:44.2]Wecanseefluidorsofttissuedensityintherightupperquadrantoftheabdomenwiththe[1:53.6]Weseeboneorcalciumdensityintheclavicle,scapulaand[2:01.5]Andthereismetaldensityonthis[2:04.9]inthemarkerthatthetechnologistcesonthefilmtoindicatethatthisisanuprightPA[2:12.1]Sotheseareallfiveoftheradiographicdensitiesthatwecanseeonachestx-[2:19.6]Howdoesthishelp[2:21.1]Well,theyprovideaclueastothecompositionofanabnormality,andtheyalsocanhelptoluswheretheabnormalityislocated,andthatwill(be)talk(ed)aboutinthenextPodcast.[2:34.9]HereisachestX-raythatyoucanpauseyourcomputerorMP3yertodeterminewheretheabnormalityisandwhatdoyouthinkitmightbe.[2:46.2]Well,you’recorrectifyouidentifiedanabnormaldensitysuperimposedontheright[2:55.1]Ifweexaminethedensityofthatabnormalitymore[2:59.2]wecanlthatitisnotalymph[3:03.3]becauseitshouldbethesamedensityasalltheotherlymphnodesinthe[3:07.7]andit’sactuallymuchdenserthansoft[3:11.1]It’snotacalcifiedlymph[3:13.5]Becausethisisthedensityofcalciumintheribs.Andit’sdenserthanthat.[3:21.0]Andyes,ifyoucorrectlyidentifiedthisasaforeignbody,you’llbecorrect.[3:26.8]Andifyouidentifieditasabullet,youwillbeevenmorecorrect.[3:32.1]So,thisismetal[3:34.6]Hereisanotherabnormality.Youcan[3:42.0]Clearly,thereisa(n)abnormalityintherightparatrachealregion.[3:47.3]Andifwelookatitcarefully,wecanseethatitissofttissuedensity.[3:51.4]It’sthesamedensityas,forexample,theheart.[3:56.6]It’sdenserthantheairinthe[4:01.1]It’sadenopathyintherightparatracheal[4:05.1]And,didyoualsoseethattherewasamassinthe[4:09.2]whichrepresentsthebronchogeniccarcinomathispatient[4:13.1]whichmetastasizetotheregionallymph[4:16.3]So,thisissofttissue[4:20.1]Here’saMiniQuizfor[4:22.0]Lookatthisradiograph.PauseyourcomputerorMP3yeranddecidewhatyouthinkit[4:30.6]Well,thereisametallicdensityrightinthemiddleofthislittlekiddy’schest[4:39.1]andit’ssuperimposedontheareawherethetrachealortheesophaguswouldbe.[4:45.9]Thismetallicdensityisacoinintheesophagus.[4:50.5]And,itactuallyrepresentedaUS[4:54.5]So,ifyoucorrectlyidentifiedthatitwasmetallic[4:59.6]youwereusingthe5basicradiographic[5:03.9]To[5:05.0]Thereareair,fat,softtissue,calciumand[5:09.7]And,byknowingthem,wecanrecognizewhatabnormalityisfrequentlyanddeterminewheretheabnormalityis. e Podcast02--TheSilhouette[0:13.4]I'mWilliamHerringfromAlbertEinsteinMedicalCenterin[0:17.7]Inthefirst Podcastwediscussed5basicradiographicdensities:metal,boneorcalcium,softtissueorfluid,fatandair.[0:28.9]Andthegraphicontheleftdemonstratesmoreorlesswhattheseradiographicdensitieswouldappearlikeonaconventionalradiograph.[0:38.0]Inthis podcast,we'regoingtodiscussbrieflyoneofthemostimportantsignsinallofradiology--thesilhouettesign.[0:46.4]Thesilhouettesignsaysthatwhentwoobjectsofthesameradiographicdensitytoucheachother,thentheborderbetweenthemdisappears.[0:55.1]Sotherearetwoconditionsthathavetobemetforthesilhouette[0:58.5]oneisthatthetwoobjectshavetobeofthesameradiographicdensity:fluidandfluid,fatandfat,boneandbone;[1:08.3]andthentheyhavetobephysicallyadjacenttoeachotherfortheedgebetweenthemto[1:15.4]Andwecandemonstratethisbythesetwocoloredcircleswhichwecanmakebelieverepresentthesameradiographicdensity.[1:22.9]Thereasonthatweseetheedgebetweenthemisbecausethereisablackcolorasabackgroundbetweenthetwoorangecircles.[1:32.2]Butifthetworadiographicdensitiestouch,thentheedgebetweenthemdisappears.[1:39.1]Andthisisanexampleofthesilhouettesign.[1:41.6]Weusethiseverydayin[1:43.9]Thereasonthatwecanseetheheartinsideofthechestisbecausetheheart is(of)fluidorsofttissuedensityandthelungsoneithersideofitcontainair.[1:54.8]Sotherearetwodifferentradiographic[1:57.4]Butifthereissomethingthatrecestheairinthelungthatisthesamedensityastheheart,thentheedgebetweenthemwilldisappear.[2:07.0]Andthisissuchacaseinwhichtheindividualhasa isoftheentireleftlung,[2:15.0]whichmakestheleftlungairless, andthesamedensityastheheart,[2:21.5]andthereforetheinterfacebetweentheleftheartborderandleftlungdisappears.[2:27.1]Anexampleofthesilhouettesign.[2:30.2]Hereisanexampleofthesilhouettesigninadifferent[2:35.4]Hereintheleftlowerlobe,whichisnormal,wecanseethelefthemidiaphragmbecausethereisaairbothontopofitand,inthiscase,inthecolonbeneathit.[2:48.3]Ifwelookattherightside,wenolongercanseethehemidiaphragm.[2:52.6]Thehemidiaphragm isinvisible.[2:56.0]Rendersobysomethingintherightlowerlobe,whichisnowthesamedensityasthehemidiaphragmandliverbelowit.[3:05.6]Inthiscase,thereisa isoftherightlower[3:12.7]whichisrenderingtherightlowerlobeairlessandthesamedensityastheright[3:19.0]makingittheinterfacebetweentherighthemidiaphragmandthelungdisappear.[3:26.0]Hereisanotherexample.[3:27.9]Inthiscase,thereisopacificationoftheentireright[3:34.7]Andwenolongercanseeanyofthesestructuresontherightsideoftheheart,theascendingaortaandtherightatrium,[3:41.0]becausetheyarebeingsilhouettedoutbythelackofairintheright[3:47.4]Inthiscase,thepatienthashadap onectomyintheright(hemithorax.The?)hemithoraxhasbeenfilledwithfluidand fibroustissue.[3:56.4]Sohereisaminiquizthatusesthesilhouettesign.[4:02.0]YoucanpauseyourcomputeroriPod.[4:08.1]Sothispatienthasa onia.Thequestioniswhereisthe [4:12.9]Andifyoulookcarefully,youcouldseethatthereisanareaofairspacedensityontheleft Andifyoulookmorecarefully,youcannolongerseetheinterfacebetweentheleftheartborderandthelung, whichmeansthatthisp oniahastobetouchingtheleftheartborder.[4:37.9]Sincetheheartisanterior,thisp oniahastobeanteriorinthelung.[4:43.0]Ifwelookatthela lviewofthisindividual, wecanseethatinfact(that)thisp intheleftlung isanteriortothemajorfissure.[4:54.3]It'sinthelingularsegmentsoftheleftupper[4:58.2]Andthat'swhy(it)the oniasilhouettestheleftheart[5:03.1]Becauseit'sthesamedensityastheheartanditphysicallytouchestheheart.[5:10.3]Thisisalingularp [5:13.1]Sotorecap.Whentwoobjectsofthesamedensitytoucheachother,theborderbetweenthem[5:20.5]Thatisthesilhouettesign. e Podcast03--Orthogonal I'mWilliamHerringfromAlbertEinsteinMedicalCenterinPhiladelphia. Orthogonalviewsaretwoviewsthatareobtainedatrightanglestoeachother. Andtheyarenecessaryinorderforustobeabletolocalizeanobjectusingconventional WhenweX-rayapatient'schest,forexample,inthefrontalor l everythingfromtheskinonthepatient'sbackthroughthelungs,thespine,theheartandtheskinonthepatient'sfront issuperimposedoneachotherontheX-raycassette. Ifthere'salesioninoneofthislayers, thenwhenwelookattheX-rayimage,itmaybedifficulttol where,fromfronttobackorsidetoside, thatlesionislocated. Ifwelookatthreehypotheticalpatients, thehorizontalgreylineshererepresenttheX-ray andthebluestructuresatX-raytubeswerelookingdownonthepatientshead. PatientAhasalesionontheanteriorchestwallanditprojectsthereonthere(?)film. PatientBhasalesionthat'sinsidethechest. Itprojectsinthesame onthere,X-ray AndpatientChasalesionposteriorlyintheskinontheback,anditprojectsinthesame Soclearlyitwillbedifficultto lfromjustoneviewwherethislesionwaslocated. Andsowe'lladd anotherviewat90degreestothefirst,anorthogonalview,representedbytheverticalgraystripes. AndinthecaseofpatientA,wecanseethatthelesionisprojectedinthatlocationontheX-raycassette. Patient it'sprojectedinthat AndpatientC,it'sprojectedinadifferent Now,ifwetakethetwopairofimages,thefrontalandla l,forpatientA,forBandfor andwelookatthemtogetherasweusuallydo, it'srelativelyeasytolocalizewherethelesionis. Nowthisisn'tasimportantasitmayoncehavebeen, becausewenowhaveimagingtechniquesthatusescross-sectional suchasCT,orultrasoundorMRI. Andhere'sapatientwhohasaCTscanofthechest,andwecanseequieteasilythatthey anodulethatisintheleftupperlobe. There'snoquestionthatthisisintheleftupperlobe.[3:13.2]It'snotontheskinonthefrontortheback. Itisinthe Butthat'snotalwayspossibletomakethatdeterminationinitially. Andhere'sacaseinwhichapatienthasametallicforeignbody. Onceagain,itisabullet. Butwecan'tlfromthisfrontalprojectionalonewhetherthebulletisintheskin,subcutaneoustissue,inthefrontorthebackorsomewhereinbetween. Andso,asyoualreadyguess,wegeta l Andonthe lview,wecanclearlyseethatthebulletisinsideofthe Andnowwehavetwoviewin90degreestoeachother,whichlocalize(to)thebullettotheinsideofthechesttothelungs. Andthisbulletactuallyisintheaortopulmonarywindow. Sothepatientisveryluckytohavesurvived. Here'sanotherexampleusingbone. Sothisafrontalviewofthefemur. Andwecanseethatthere'sadensecalcificationthatissuperimposedonthedistalfemur. Thiscalcificationcouldbecortical,itcouldbeintramedullary, orconceivablyitcouldprojectoutsideofthefemur. Andsoifwegetanotherviewat90degreestothefirst,anorthogonal wecannowseethatthedenseamorphouscalcificationlieswithintheintramedullaryontheorthogonalview. Andtherefore,sinceitisintheintramedullaryonbothviews,itrepresents,inthiscase,anoldboneinfarct,oneofthecausesofmedullarycalcification. So,thisisyour YoucouldputyourcomputeroriPodonpauseandtakealookatthischestX-rayanddecidewhat'sthenextstudyisthebesttoget. Well,hopefullyyouwereabletoseeanodule intheleftupperlobeofthispatient oratleastsuperimposedontheleftupperlobeofthispatient. And yousaidthatthenextimagethatyouwould wouldbea lviewwhichisacloseupwe'reshowingyouofthe l Andifyoulookverycarefully,thereisalesionthatisprojectingoutsideofthechestonthepatient'sskinonthela lview. Thisactuallyrepresentedamoleonthepatient's So,itwasveryimportanttoobtaintwoviewsat90degreestoeach todemonstrate notonlybyphysicalexaminationbutalsobytheX-raythatthisisalesionthat'soutsideofthechest. Sotorecap.Orthogonalviewsaretwoviewsthataretakenatrightanglestoeachother. Theyarekeytolocalizingobjectsonconventionalradiography. This Podcast04--PulmonaryImagingDifferentialDiagnosis,part o,I’mWilliamHerringfromAlbertEinsteinMedicalCenterin Thesedifferentialsarenotintendedtobeall- Theyaredesignedasanaidtorememberingafewofthemostimportantcausesforeachofthefindingsshown. Consultatextbookforall-inclusive Howthispresentationworksis:first,acaseisshownasan You'll(do?)identifythedifferentialthatthecaseisexemplifiesusethe pausecontrolonyourcomputerorMP3yer. Thenextslidewillbethetitleofthedifferential,inthis anteriormediastinal Againusethepause Thenextslidewillrevealthedifferential Andthelastsliderevealsthediagnosisoftheoriginalcase Thispodcastisdesignedtobeusedaseitheranaudio-onlypodcastor-onlypodcast,or Let'sbeginwiththenext Thisisthe Anteriormediastinalmasses.PauseyourcomputerorMP3 The4causesare toma,substernalthyroidandlymphoma. Thisisthesecond Thedifferentialisacuteairspacedisease.Thereare4 Thecausescanbepulmonaryedema,p onia,aspirationorhemorrhage.(Non-cardiogenicPulmonaryEdema) Thisisthenext Thedifferentialis omediastinum.Thereare5 Causesincluderupturedesophagus,rupturedtrachea/bronchus,iatrogenic/traumatic,asthma,orsometimesp .(Asthmaticwithp Thisisthenext Thedifferentialischronicairspacedisease.Thereare4 The4causesofchronicairspacediseasearealveolarcellcarcinoma,alveolarsarcoid,lymphoma,andalveolarproteinosis.(Alveolarsarcoid) Thisisthenext Thedifferentialisforanopacifiedhemithorax.Thereare4 The4causesofanopacifiedhemithorax area is,pleuraleffusion,p onia,and Thisisthenext Thedifferentialisforlargecavitarylunglesions.Thereare3causes. Thecausesforlargecavitarylunglesionsincludeabscess,carcinomaandtuberculosis.(Carcinomaofthelung) Thisisthenext Thedifferentialisforupperlobedisease.Thereare4possible Thecausesofferedaretuberculosis,silicosis,eosinophilicgranuloma,andankylosingspondylitisforupperlobedisease.(ProgressiveMassiveFibrosisinSilicosis) Thisisthenextdifferential Thedifferentialisforbibasilarinterstitialdisease.Thereare6causes The6causesare is,chronicaspiration,desquamativeinterstitial asbestosis,sicklecelldiseaseandscleroderma. Thisisthenext Thedifferentialisformicronodularlungdisease.Thereare4causes Thecausesofmicronodularlungdiseaseincludemetastases,sarcoidosis,p andmilliarytuberculosis.(Milliarytuberculosis) Thisisthenext Thedifferentialisforsmallcavitarylunglesions.Thereare4causes Thecausesofsmallcavitarylunglesionsincludesepticemboli,rheumatoidnodules, squamousortransitionalcellmetastasesandWegener'sgranulomatosis.(Septicemboli) Thisisthenextdifferential. Thedifferentialisforlymphangiticspreadtothelungs.Thereare6causes Causesoflymphangiticspreadtothelungs lungcancer,breastcancer,stomachcarcinoma,pancreascarcinoma,laryngealCAandcervicalCA.(LymphangiticSpread-LungCancer) Thisisthenext Thedifferentialismultiplelung Thereare5causes Fivecausesformultiplelungnodules metastases,Wegener'sgranulomatosis,rheumatoidnodules,multipleAVMs,andsepticemboli.(Metastasesfromcoloncarcinoma) Thisisthenext Thedifferentialisforpulmonaryinterstitial Thereare3causes Causesofpulmonaryinterstitial congestiveheartfailure,lymphangiticspread,andallergicreaction.(Congestiveheart Thisisthenext Thedifferentialisforshiftinginfiltrates.Thereare6causes Causesofshiftinginfiltrates Loeffler'ssyndrome,allergicbronchopulmonaryaspergillosis(ABPA),asthma,aspiration,polyarteritisnodosaandviralp onia.(RecurrentAspiration) Thisisthenext Thedifferentialisforchronicinterstitialdisease,orpulmonaryfibrosis.Sixcausesare Possiblecausesforchronicinterstitialdisease oconiosis,interstitialp onias,granulomatousdiseases,neosticdiseases,ideopathicfibrosisandcollagenvascular Thisisthenext Thedifferentialisfora lhyperlucentlung.Thereare4causes Fourcausesofthe lhyperlucentlung Swyer-Jamessyndrome,pulmonaryembolism,p othorax,andobstructiveemphysema.(ObstructiveEmphysema) Thisisthenext Thedifferentialisrapidlyclearingairspacedisease.Thereare4causes Causesforrapidlyclearingairspacedisease hemorrhage,pulmonaryedema,aspiration,andp ococcalp Thisisthenext Thedifferentialismasseswithairbronchograms.Thereare3causes Causesformasseswithairbronchograms lymphoma,alveolarcellcarcinoma,andpseudolymphomaorMALToma(Mucosa-associatedlymphoidtissuelymphoma).(Lymphoma) Thisisthenext Thedifferentialisforacavitating onia.Thereare4causes Causesforacavitating onia staphylococcal,streptococcal,tuberculosis,andGramnegativep onias,suchasKlebsiella.(StaphylococcalP Thisis Podcast05--PulmonaryImagingDifferentialDiagnosis,part2.[0:15.6]I'mWilliamHerringfromAlbertEinsteinMedicalCenterinPhiladelphia.[0:19.5]Rememberthesedifferentialsarenotintendedtobeallinclusive.[0:22.8]Theyaredesignedsimplyasanaidtorememberingafewofthemostimportantcausesforeachofthefindingsshown.[0:29.6]Thewaythepresentationworksisacasewillbeshownfirstasanexampleofthedifferentialto[0:35.9]UsethepausecontrolonyourcomputerorMP3[0:40.0]Thenextslidewillbethetitleofthedifferential,andthenumberof[0:45.7]Againusethepause[0:47.9]Thenextslidewillrevealthedifferentialdiagnosis[0:51.9]Andthelastsliderevealthediagnosisoftheoriginal[0:56.1]Thispodcastisdesignedtobeusedaseitheranaudio-onlyor -onlypodcast,or[1:04.6]Here'syourfirstdifferential.Pausethe[1:09.7]Thedifferentialisformiddlemediastinalmasses.Thereare4causes.Pausetheyer.[1:17.2]The4causesofmiddlemediastinalmassesarelymphadenopathy,aneurysms,esophagealduplication,andbronchogeniccysts.(BronchogenicCyst)[1:29.3]Here'sthenextdifferential.Pausethe[1:34.7]Thedifferentialishilaradenopathy, lor [1:39.6]Thereare5causes.Pausethe[1:45.0]Thedifferentialdiagnosisfor lor lhilaradenopathywould[1:50.3]sarcoid,whichisusuallybila [1:53.3]tuberculosis,whichisusuallyunila [1:56.0]lymphoma,whichisusuallybila [1:58.8]bronchogeniccarcinoma,usually [2:01.9]andmetastases,whichcanbeeither lor [2:10.5]Here'sthenextdifferential.Pausethe[2:16.4]Thedifferentialiscavitiescontainingmasses.Thereare4causes.Pausetheyer.[2:24.5]The4causesofcavitiescontainingmassesareaspergillomas,cavitatingbronchogeniccarcinomas,tuberculosis,andhydatidcysts.(Aspergilloma)[2:39.5]Here'sthenextdifferential.Pausethe[2:46.7]Thedifferentialisairspacediseaseswitheffusion.Thereare4causes.Pausethe[2:55.3]The4causesofairspacediseaseswithpleuraleffusion[2:58.5]staphylococcalp onia,streptococcalp onia,tuberculosis,andpulmonaryinfarct.(StaphylococcalP [3:09.0]Here'sthenextdifferential.Pausethe[3:15.9]Thedifferentialisamassordensityinthelungwithipsila lhilaradenopathy.Pausethe[3:27.7]The3causesofamassordensitywithinthelungwith lhilaradenopathywould[3:33.6]bronchogeniccarcinoma,lymphomaandtuberculosis.(Bronchogenic[3:44.6]Here'sthenextdifferential.Pausethe[3:54.6]Thedifferentialisasolitarypulmonarynodule.Thereare8causesinthelist.Pausethe[4:06.0]The8causesofasolitarypulmonarynodulewould[4:10.4]abronchogeniccarcinoma,hamartoma,histosmoma,tuberculous[4:16.9]bronchialadenoma,solitarymetastasis,roundp onia,androunded [4:29.0]Here'sthenextdifferential.Pausethe[4:36.3]Thedifferentialisforaleft-sidedpleuraleffusion(s).Thereare4 Pausethe[4:45.1]The4causesofaleft-sidedpluraleffusioncan[4:49.4]Boerhaave'ssyndrome((氏)综合征:自发性食管破裂综合征),adissectingaorticaneurysm,pancreatitis,oradistalthoracicductrupture.(DissectingAorticAneurysm)[5:02.6]Here'sthenextdifferential.Pausethe[5:08.3]Thedifferentialisforpleuraleffusions.Thereare9possiblecauses.Pausethe[5:17.7]Causesforapluraleffusion[5:20.4]congestiveheartfailure,metastases,[5:24.1]pulmonarythromboembolism,trauma,[5:29.1]collagenvasculardisease,andovariantumor(Meig'ssyndrome:某些良性或恶性盆腔肿瘤(特别是肿瘤)伴大量胸水腹水胸水常见于右侧,也可见于两侧,肿瘤切除后,胸水才),andchylothorax.(CongestiveHeartFailure)[5:40.0]Here'sthenextdifferential.Pausethe[5:48.1]Thedifferentialismultiplesmallcalcificationsinthelung.Thereare5causes.Pausethe[5:58.1]Thecausesofmultiplesmallcalcificationsinthelunginclude[6:01.7]histosmosis,silicosis,chickenpoxp onia水痘,[6:05.9]pulmonaryossificationsecondarytomitralstenosis,[6:09.4]andrarely,alveolarmicrolithiasis.(ChickenPox onia[6:18.1]Here'sthenextdifferential.Pausethe[6:25.2]Thedifferentialdiagnosisisforaposteriormediastinalmass.Thereare3causes.Pausethe[6:34.9]The3maincausesofaposteriormediastinalmassareneurogenictumors,lymphadenopathy,orextramedullaryhemopoiesis（hematopoesis）.(Neurofibroma)[6:49.8]Here'sthenextdifferential.Pausethe[6:57.2]Thedifferentialismediastinaladenopathy.Thereare5causes.Pausethe[7:05.8]The5causesofmediastinaladenopathycan[7:09.2]bronchogeniccarcinoma,lymphoma,tuberculosis,metastasisand[7:21.9]Here'sthenextdifferential.Pausethe[7:31.6]Thedifferentialislungdiseasewithassociatedrib[7:36.6]Thereare4causes.Pausethe[7:41.8]The4causesoflungdiseasewithassociatedribdestruction[7:45.7]bronchogeniccarcinoma,suchasaPancoast[7:48.9]actinomycosis,blastomycosis,andmultiplemyeloma.(Pancoast[8:03.3]Here'sthenextdifferential.Pausethe[8:13.3]Thedifferentialispleuralcalcification.Thereare3maincauses.Pausethe[8:21.0]The3maincausesofpleural[8:23.9]areanoldtuberculosisempyema,asbestosexposure,orhemothorax.(Asbestos[8:38.1]Here'sthenextdifferential.Pausethe[8:45.0]Thedifferentialisfor"masses"inthecardiophrenic[8:49.6]Thereare3causes.Pausethe[8:54.7]Thecausesofanapparentmassinthecardiophrenic[8:58.4]includeasequestration,diaphragmatichernia,orpericardialcyst.(Morgagni[9:11.0]Here'sthenextdifferential.Pausethe[9:17.9]Thedifferentialis lpulmonaryedema.Thereare3causes.Pausethe[9:26.1]Thecausesof lpulmonaryedema[9:29.3]rapidexpansionofap othorax,orrapidwithdrawoffluidfromapleuraleffusion,[9:35.9]postural,ordiseaseintheotherlung,forexample,chronicobstructivepulmonarydisease.(Re-expansionPulmonaryEdema)[9:46.7]Here'sthelastdifferential.Pausethe[9:52.4]Thedifferentialisreverse"pulmonaryedema".Thereare3causes.Pausethe[10:01.0]The3causesareeosinophiliclungdisease,forexample,Loeffler'ssyndrome,oreosinophilic [10:07.7]sarcoid,orpulmonarycontusions.(Loeffler's[0:08.4]ThisisPodcast06from [0:16.1]TheSalter-HarrisClassificationofEpiphysealFracturesinChildren.[0:21.4]I'mWilliamHerringfromAlbertEinsteinMedicalCenterinPhiladelphiafor[0:26.6]Epiphysealtefracturesarerelativelycommonfracturesin[0:30.9]Theyoccurthroughtheweakestpartofthegrowingbonetheepiphysealte.[0:36.3]Mosthealwithoutanyproblems.Complicationsarerare.[0:40.1]Andconventionalradiographyisthestudyof[0:44.2]TheSalter-Harrisclassificationdividesthesefracturesinto5different[0:49.1]Therehavebeenothercategoriesatthesubsequently(?),buttheyarelesscommonfractures.[0:55.5]Andtheclassificationprovidesprognosticcluesaswe'llsee.[1:00.2]Thehigherthenumberoftheclassification,theworstprognosisandthegreaterthechanceof[1:07.9]Theboneisdividedintothediaphysis,themeataphysis,the[1:14.9]Andbetweenthemeataphysisandtheepiphysisliestheepiphysealte, alsoknownasthephysisorthegrowthte.[1:23.8]AlloftheSalter-Harrisfracturesaregoingtoinvolvetheopenepiphysealte.[1:30.6]ASalter-HarrisIfractureinvolvesonlyepiphysealte,[1:35.5]unlessthereissomediscementoftheepiphysisonthemetaphysisorwideningoftheepiphysealte.[1:42.9]Thesecouldbeimpossibleto[1:45.8]Theytendtohealquicklyinamatterofjustfewweeksandcomplicationsarerare.[1:51.9]Salter-HarrisIfracturesaretheresultusuallyofshearings.[1:57.3]And,asIsaid,unlessthereisdiscementofthemetaphysisontheepiphysis,theycanbeverydifficulttodiagnose.[2:06.0]Sometimes,obtainingtheoppositesideforcomparisoncanbehelpfulindemonstratingwideningoftheepiphysealte.[2:15.5]Sometimes,afteramatterofseveraldaysof[2:19.7]periostealnewboneformationcanpresentitselfandindicatethe presenceofafracture.[2:26.3]ThisisanexampleofaSalter(-Harris)Ifracture.[2:30.4]Thisistheproximal[2:35.2]AndIthinkyoucanseethatthereisdiscementoftheepiphysisonthemetaphysis.[2:46.3]Andthereisalsowideningoftheepiphysealte.[2:52.1]Salter-HarrisIIfracturesarethemostcommontypeofepiphysealtefractures.[2:59.0]Theyinvolvebothepiphysealteandthemetaphysis.[3:03.3]Frequentlyacornerofthemetaphyisseparatesfromtheremainderthethemetaphyis.[3:09.1]Andtheserarelyproducecomplicationsonhealing.[3:12.7]SoaSalter-HarrisIIfracture,astheblacklineshows,involvesusually acornerofthe[3:20.8]Veryfrequently,thatcornerremainswiththeepiphysiswhiletheremainderofthemetaphysisisdisced.[3:29.9]Thecornerissometimecalledthe"cornersign".[3:32.9]Itisalsocalledthe"Thurston-Hollandsign".[3:36.1]AndhereisanexampleofaSalter-HarrisIIfractureoftheproximalphalanxofthethumb.[3:43.8]AndIthinkthatyoucanseethat,righthere,[3:50.6]thereisafracturelinethatseparatesthistinyfragmentfromtheremainderofthemetaphysis.[3:58.8]Thisisthemetaphysis.[4:00.4]Nowecan'tseethefracturethroughthegrowthte[4:05.3]ButthisisaSalter-HarrisIIfracture,thereisafracturethroughtheepiphysealte.[4:11.7]Salter-HarrisIIIfracturesarefracturesthroughtheepiphysealteandtheepiphysisitself.[4:18.1]Becausetheyinvolvetheepiphysis,theyextendtothejointsurface,andbecausetheyextendtothejointsurface,[4:24.8]theycaninvolvethearticularcartilageandresultindamagetothearticularcartilage.[4:32.1]Theyrequireearlyreduction.[4:35.5]SoaSalter-HarrisIIIfractureisafracturethatextendsthroughtheepiphysealteandthenalsothroughtheepiphysisitself.[4:48.4]ThisisanexampleofaSalter-HarrisIIIfractureofthedistal[4:53.1]Youcanseethatthereisalinealradiolucencythatextendsthroughtheepiphysistothearticularsurface.[5:04.9]That'sgoingtoresultindamagetothearticular[5:11.8]Salter-HarrisIVfracturesinvolvetheepiphysealte,theepiphysis,andmetaphysis.[5:20.2]Becausetheyinvolvetheepiphysis,theydoextendtothejointsurface.[5:24.0]AndSalter-HarrisIVfractureswilloftentimesresultingrowthdisturbance,orangular[5:33.7]ASalter-HarrisIVfractureisafracturethroughthemetaphysis,throughtheepiphysis,andtothearticularcartilage.[5:46.6]Becausethefractureextendsthegrowing[5:51.5]itfrequentlyresultsinangulardeformitiesorgrowthdisturbances.[5:57.1]HereisanexampleofaSalter(-Harris)IVfracture.[6:03.6]Thisisthedistal[6:05.9]Andyoucanseealinealradiolucencythroughthemetaphysis,andalinealradiolucencythroughtheepiphysis.[6:14.9]Sothisfractureextentsthroughthemetaphysis,throughtheepiphysealte,anddownthroughtheepiphysistothearticularcartilage.[6:28.1]Salter-HarrisVfracturesare[6:31.1]Theyarecrushorcompressioninjuriessecondarytoaxialloadingratherthanshearinginjuriestotheepiphysealte.[6:39.0]Theinitialdiagnosisofthismaybeimpossibleandtheymaybeonlybevisibleafterthecomplicationsensue.[6:47.0]Salter-HarrisVfractureshavethehighestincidenceofangulardeformities.[6:52.6]Theyresultinaxialloadingwhichcrashesorcompressestheepiphysealte.[7:03.3]Thatmayproduceearlyfusionoftheepiphysealteinoneareaandnofusioninanother.[7:13.5]Sothatthereisanangulardeformitythatdevelopsintheboneinvolved.[7:19.1]Andhere'sanexampleofthatinthedistal[7:24.6]Onthemedialsideofthejunctionbetweentheepiphysisandthemetaphysis,thereisfusion.[7:34.8]Onthela laspectoftheepiphysealte,theteremainsopen.[7:41.6]Andthathasresultedinanangulardeformitybecausegrowthstopedmediallywhileitla [7:50.5]Soto[7:51.6]SalterIfracturesarefracturesthroughthe te[7:56.7]SalterIIfracturesarefracturesthroughtheepiphyseal teandthemetaphysis;[8:01.2]SalterIIIfracturesarefracturesthroughtheepiphyseal teandtheepiphysis;[8:06.1]SalterIVfracturesare