Table Of Content

Harris &H arris' The Radiology of Emergency Medicine Harris &H arris' The Radiology of Emergency Medicine EOITEIIIY Thoma1 L Pope, Jr., MD, FACR .r Fonnort,: ,....,.. ., .t llediDIDIJ ond Orthopoodict, Uniwonily Vi'tilia w• IChorl-..llo, Wol, Preleu• of Rodiolofy ood Ot'lllopoodicr, ForiSI Unlwonlly Schaal DllolodlciMC fWh•II•I IIDn-5olom, NCI .,d Pralo-rI ll llodiDIDIJ .r ood Ot'lllapoodloo andfonnar RodiDIDIJ, Modlcol Unlw111~ .,....,.. CorDinoiChorlollllll, SCI ca. ... .,, l"n•mly: bdloloallt Dlnlcll Spada~ Boord llediopilora Nltionol Raololotl' &ra~p a. . d!wood, OH ond\Yuttlort, CT CIIEDnOR Joh• H. H•rria,. Jr. . MD, DSc, FACR. FRACR (Hon) Dls•taulltlld EllwluePtd llllrlfAIIIIIIf u•a•lf'- TM Mlllut &eMil It ll1dl1 Ho-n.T-• -.. ...e lllodiollltY lit. JooopAh~r iH...•,p. fteland Modlcll lcholl Phlllilc. I ~....l.e.1'.5. K..lu. w_er Lippinoott WIKiams a. Wlllcfns ...,. ..... . Md''z'••.....,_•-M•. ..... Senior Executive Editor: Jonathan W. Pine, Jr. Product Manager: Amy G. Dinkel Vendor Manager: Alicia Jackson Senior Manufacturing Manager: Benjamin Rivera Senior Marketing Manager: Kimberly Schonberger Designer: Teresa Mallon Production Service: Absolute Service, Inc. 0 2013 by LIPPINCOTT WILLIAMS &WILKINS, a WOLTERS KLUWER business Two Commerce Square 2001 Market Street Philadelphia, PA 19103 USA LWW.com All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means, including photocopying, or utilized by any information storage and retrieval system without written permission from the copy right owner, except fur brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. Printed in China Library of Congress Cataloging-in-Publication Data Harris & Harris' radiology of emergency medicine I edited by Thomas L. Pope Jr. ; co-editor John H. Harris Jr.-5th ed. p.;cm. Radiology of emergency medicine Rev. ed. of: Radiology of emergency medicine I John H. Harris Jr., William H. Harris. 4th ed. <:2000. Includes bibliographical references and index. ISBN 978-1-4511-0720-3 (hardback: alk. paper) L Pope, Thomas Lee. IL Harris, John H., 1925-IlL Harris, John H., 1925-Radiology of emergency medicine. IV. Title: Radiology of emergency medicine. [DNLM: 1. Emergencies. 2. Emergency Medicine-methods. 3. Radiography-methods. WB 105] 616.07'572-dc23 2012030187 Care has been taken to confrrm the accuracy of the information presented and to describe generally accepted practices. How ever, the authors, editors, and publisher are not responsible fur errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of the information in a particular situation remains the professional responsibility of the practitioner. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with current recommendations and practice at the time ofp ublication. However, in view of ongoing research, changes in government regulations, and the constant flow ofi nformation relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precau tions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223- 2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service representa tives are available from 8:30am to 6 pm, EST. 10 9 8 7 6 5 4 3 2 1 I dedicate this book to the uncountable number of fellows, residents, and medical students with whom I have interacted in my career. All of them have taught me aspects of lifelong learning in some way which all humans, especially physicians, should embrace and practice with enthusiasm and commitment; to my two sons, David and Jason, whom I know live their lives by this basic principle; and lastly, to my significant other, Dr. Jennifer Newcomb Cranny, who is a constant and solid pillar ofs upport for me personally and professionally. -TLP,Jr. To the members of the Church of the Red Rocks (Sedona, Arizona), whose steadfast love and support sustained my wife, Cathy, and I during her terminal illness, and which will sustain me the rest of my life. -]HH,Jr. CONTENTS tz ~;, c:t1at: N0111:r1uma ••••••••••••••••••4 41 _t..._onllr"J.- ,.""''"' » I'W/ftliiO ... RJilo Billlotl ""' 13 Chl!ll: 1l'aumA .......•••••••••.... . 419 I'W/ftliiOI.I.f...o..- - ... ""*'H.IWIWJr.nla.tE.JAN ~ 14 AbdOIIICIII Noalnlllllllil: Pm.crga.cia •••• 573 0 •••••••••••••••••• 1 .............•.......•. 1 ~~ IS AbdomtJ~: 'Dlwmatlo:~ .... 661 -AS..D.Oorle--1!.- ... 2 Ingin1 c:lfBrlUul 1-bw-Da, , ............ 15 ....H .HdJ1, J.rr.ttltlt!tll,ll. ........ .-.a.c~. S NoDil'lu!DIIIc~Emolgmcla. ..! IS Scrotal~ ...••••••••..... 707 -Y.ttro. .. n.uma ......... ll:lblltO.Hdf.~ftll>.......,..., t Imapg Muillo&cial 91 .lc*tH."'-*Jr. .. w.P.a.n..~n.~:...,a.a...wJ H.t~~nJt i Ccrvic:al Spine IDjuria •• 139 'Iiact 'l\s11111& •••••••••••••••••••••• 74'1 0 0 0 ••••••••• .1*11. Hn Jr. I 'lbe PMI&uk OeniW SpiDt ......... 241 II .A.ccta'bt.alu:aa ••••• llS I ••••••••••••••••• ~£.t 7 ....... tftiK.~& w..,.&.-.. ... t. .K .HM'I& J I,..p., 'l11om:olamhor 11 .H,..lHp.u .n.d.. PMalnuol Pem!m ..........1 31 _ Spine 'D'auma. ••.............••••••2 65 ..... Jt. H...,... aa.t P.llrnlaln.N-*1.. ._1MJ lh A • Kace 0" I I- I "0 0 '0 0" 0 I' I- I .I I, 0 _0 0 0• .0 o o o .0. .0 0 0 0 0 0 861 I Shoulder.ID.dud!Dt Oavlclt mel SCipu1a •••• 307 2:t Ankle •••••••••••••••••••••••••••• 90S 0 0 ••••••••••••••••• .lllw!H. ......... & 1 Blbow •••••••••............••••••• m ZZ l"oot mel Hftl ......................... N:7 __ .,.MoNoi~--L ...... c.IJOI ,._...,.,K.~ JftK..,.,. &. • 1D Wlilt .•••••••••.............••••• ,,Tl - L ... .. _., ___l l_ .k D Dlaphyolo ......................... m ,, liancl ............................... 42.1 Jtlfr!IU. 'tliln....,.._.L,....& wii CONTRIBUTORS lllomo..__ of-- pf B,.Oorff.wr.,lilQ. dCa I ... lctclldllutlw:bn' ~ DOjiCWofMIMokv l>ltto!a::. Ml:twlotloll'll>lo ""'- ~o!lf<>olh~$clooolofMJolicino •ooliolou Cbqd lllD. N<>olh <liR>IIDa Alllll:mra-1 iloiJllill """""""· ,.,..,_. A4l'ol44 DteMe A """"111,.81 Q{Jda;l Plo£ , r JJ.....-of-a.:-J iad!oloir or,.=tdtJwUo'otr I.t..o.ot.da.t,. '.I.1_.JI.,I>..o.l , ... .K.o.. o,pi_itUo NHS'Ihul .1J'.lll:- l":'pMlr-p ~l:!.' -.,u- S.du:o:oal o tMocllrl•• --~ StatJ'R•·"olopt DOjiCWofloa!oJocr i>IIUIU>'O:h-Hild:a:d:: Moe:llcol ea:. NYU 'apm• w.d,iQI c.n.t. t.oo.:--"-""" Mowll>dr.II.,.Yo<k A Jpud Ftu&tlc::lr MIIII:P.Bcrr e ··,am ~I_..Sio\o_rrm N4t0of :Illi:o<t'oo_l l$rcl.ol .ooo. o. l. . ~ -.~. -IIUI--IadlolOII' DOjiC-ofiiiMokv lml.._la.l.o. dloii~~HI>opttsl 110-llJ lalt:.IID --~ Co-JXnctor ot'Ultl:ulnmi ~ IIDAIJta•ri o..,.._otlllol>'olos7 ~qiWo4i«>>.., ~~--tlllf l) ~·~MlltrWOmla' Mowll>dr.Mnrllo<k u-.HewH1• a±> -ofllldiolcv.,..~ Mat-~ C 1 t rJL Dell Gdld Sclaoo1 ofVcdldnc DOjiCWofloMokv -MowHompol:lro ¥ lbapool ~Hoep11>1 J'-'7CilPW~ Inupooillzli.,ooaitr u.a,o<o~. 'II&!Oid J[!o. .a m --Coo~Ar.IIID.I'ACR Aat:ar*'DIN~ - otJWIIolcv Awei&M.Jawb.MD - ~o!N<>olh~ Dl. .......l adlolotlot Cbqd lllD. N<>olh <liR>IIDa - -of,_-""'"""' 'll:< lll>MniiJ Cc.ln bbl: • ·na~MIICI\nca ~---llavnbh'«Uil ......... Dopcl I tofiii:Jololr _ ..L tla:art.IID I:IMor.d.loJallnftiBMI ' W!oloPt WU:IIo:II!gplom ~~~ ~-Loo«::nnl' IAd..trb-tl-t.i"U"a'f ~ MMJctoe h"*r $odlt, """'"'~~"" l:la)l: ~o!Loldo I.oodt, 111*11 ........... X Contributors Ken F.linnau, MD, MS Emma L. Rowbotham, MB, BS Staff Emergency Radiologist Department of Clinical Radiology Department of Radiology Leeds Teaching Hospitals NHS 'frust Harborview Medical Center Leeds, United Kingdom Assistant Professor Department of Radiology J, Keith Smith, MD, PhD University of Washington Attending Radiologist Seattle, Washington Department of Radiology University of North Carolina Memorial Hospital Eugene McNally, FRCPI, FRCR Associate Professor of Radiology Consultant Radiologist University of North Carolina School of Medicine Department of Radiology Chapel Hill, North Carolina Nuffield Orthopaedic Centre Jorge A. Soto, MD Honorary Senior Lecturer Associate Professor of Radiology Oxford University Vice-Chairman of Radiology Oxford, England Boston University School of Medicine Boston, Massachusetts Stuart E. Mirvis, MD, FACR Director of Emergency Radiology Eric J. Stern, MD Department of Diagnostic Radiology and Nuclear Professor of Radiology Medicine Adjunct Professor of Medicine Professor of Radiology and Nuclear Medicine Department of Radiology University of Maryland Medical Center University of Washington Baltimore, Maryland Seattle, Washington JolumyU. V. Monu, MB, BS Leonard E. Swischuk, MD Director, Musculoskeletal Radiology Pediatric Radiology Imaging Sciences The University of Texas Medical Branch Strong Memorial Medical Center Galveston, Texas Professor of Imaging and Orthopedics University of Rochester 0. Clark West, MD, FACR Rochester, New York Diagnostic Radiologist Memorial Hermann Hospital Curtis R. Partington, MD, PhD Texas Medical Center Radiologist Houston, Texas Imaging Center of Louisiana Baton Rouge, Louisiana Anthony J, Wilson, MB, ChB, FRANZCR Retired Professor of Radiology Philip Robinson, MB, ChB(Hons), MRCP, FRCR Spanaway, Washington Department of Musculoskeletal Radiology Leeds Teaching Hospitals Sarah Yanny, MRCP, FRCR Leeds, United Kingdom Consultant Radiologist Department of Radiology Stoke Mandeville Hospital Buckinghamshire, United Kingdom FOREWORD It;, illilu.t a pl<amr• ana an bOD.IK' tQ be &UN ""'J.""lto; ,.m8 ~ aa.a m•.-ill dini· b> write tiM i:Attdll<lia for the fifth ediiioll <&I d i 'i". .... &Dil proc:tioe.lll O<ldil.i"' to ..,w;.;• • of TM ll&dlllloty •f B"""t«q Mt.udr1t, <dlt<d th< !mpoxW>u of tUD<Iarilldlogrqho, the tlfth by Thomu L. Pope, Jt., aD<I Johll H. Harril, Jr. <<lilian hu.iDccrpO<IIIdhiglt-<plil.y mnltja n;, "duoir!' tatb<lok ..... wtil bowu to .... «<mpol«< ~"!'bit (CT) im•p 3·D nforma. u a relldoat lA ~tAWNI'Ii'ltY dlltUI& my to~& llo:a.t, &11.4 ~ -lmaJIQe co p!'(lridt dOil ID th< <m<fi<llq> dcpl!1m<:Dt (BD), Aho, .,.,I Dfcnxuttlonwlll> evolv!a&clf•lcol p!¥1!cc. Fer -..w.a• wl>mDr. Hatria from l>il pollit>o:D.II1 tiM ~ tiM duf>ter dedbted to d>at -""" UIU>m!tyofTau·li(TQfii)DanaQU>letoA.rla:oDa. ¢DIT hJahl\llfrt• w ~of tt<t~At.:.l f&cllm h< wu IDtro<laud to .,. u tl>< •py whll wt0tt 111 !ll!apretlnc~ do.at ..a r"P"!''h>boltoloo tiM book. .. eDI"l'<II.C)' radioi"1Jl'."l-ftllil:ed ~lllt~n:li&D<cOilCT ~otil. that dW-watllve, beth litmlly &11.4 6,t Mot<omotht<hptulouaddold --.. ul'~t~Ydr. Fer th< put 40 J'CU'> Dr. John Harrlt' ofp rutlcallmonnat!Oilii.Ot ODir fMtll< ~ d<ilicaiOil to his ...u . .. .,. . ill radiolofr &Dil hiJ lntt ako fo: clinician• ilmlft,d. int he clir«t ....,o f iAtellectu&l <ollllKila b> ~ m.oclicill.e tiM patial.t. ph~· &11.4 tn""'' ......... mUt !hi$~ FWlly,lllt «<l!od ~II) &ldt .. d,n&m[c ma.,..• book "the tt&D<~&n~ tor~ ;,.. u ....Uoiorr aD<I """'1J''JlC1 ....., ;.. ..n.~mt ill 111t ~ fw tw:Jiili"Ymeclici~ellld tnama. He il diort 1111111111 beeo taka!. to~ Ill< 6.flil. -o_f.~ .hIoDt<! Otat tftdlolo&W who-out of th< ..Utio.o. It will «mmiAuo II) be roqolalt ~ fw "btt tiM llPt oft he trtuma bay aD<I the racllolocr r<tldenla. ~ radl.olo&foco, and ED to g;. . ral·1im.e ill:u:<pretlliOilJ lll-lidl iloiK:1ulJ.. «irridam a1W:. AlJo, the im.&p dsat..., ...a.ble ..m dew of p&lleat ~m.,... ()1). <O'Diltletf ... tb.t oDllno vmloA of !hi$ edlllo:o. pt'<lridt 1 """'WoDd Dr. Ha.rrloln our trcma reeotna, ~ 'ftfaible «<a.catlonil ra001«t for r<#· rt:ritwi:at ma am., ndiogrt~~hl teaching our raj.. datto, nodiolorr ana """"P""f moc!iant fatuity, d-&lld llla~dU.p tile Jlll&IX<J ofilllupreliJii &11.4 froalljllf ~to:r-to ....... -.411211oD&l. "'~· The fifth clli!Xm hu arpin lllrivcd to k<cp ap s..tt R.l'!llr•-. MD, l'ACS willl th< d!~t""""olotr. iD ~imaai"i ~of~~loA'I.l'Anmity lA llddlllool II)~-p;ntWt lD liD& Cl!n!raJ P~ ofS11tP!'f and trcma CCDI<:rt. N. . <l>aplm c lmllPDC of ~ofAr!JGaa olullfru:llua. -rin.ti<ial-do.at- Medical DiRcloro N::S LIMI. I 'lnllllla C...t« 11114111t~hMbtell~!l>chlt~ SL lQMPh't HolpiW UJd MOidie<ll CeDiot II) cmphulr.c tiM impOI'I&r>« oftheoc ...... wtt1l Phoenbj A.ril.t1aa PREFACE TO THE FIFTH EDITION '* lam very p:roud to wd=me To mary Pope. MD Tilt lillh edition 'l1l.r R<oolio/#:y of_,.,.., .., il>lml&tio:IW!y ........i &eci.ID'IIIC1I!otbl Uulil:ift 1 comi.rta <If :Z,) dtlpt.en,. lDckJ ding &ix DeW rdlolo&in-u<O<dltor of~ flfth~<JfTII# cllcptauDCicpprorf....ulr I,OOOP"C''tq>lcuwlth ll.luliJ>ft!ry<if-t:t""Y ~. Tomar(• ~ -.ot'tho-artMPCTma ~(VS) imsp tio». t]:arQnpiJIQ.t t:be world n.dioJ.osic commn:a.ity ...,.,. ... c.o~wt.icl> ~palialt-· pndo.clu lllo~~tod lOt • -li>rmal !mtodoal<m COQ¢1 ~ 01' tn..w riW. Eub. clutp~et II= hu bca1 ~ rm.cd to lncl!ldo coii!Cmpo· II wu Dr. hpe'a r«=nvndotio:D.IIIat we ob lllfW. I!i"•' ¥J•. adi'i i:•G oDI-U-~~U .pN! o<olt. -&'·ue.d..iat.iG tdD. -~ fotuufy~~ which <OO:DiaiAt-lilc. 2,000 tm.-ot t¢hem&tk WL· hub= a.:ccmpiUh.ccl. It wu DT. Popo'o"'""'" tom!< dmrlnp d. chc IIWIIIJCript. tKm tlu.t "" thould """""' DQ.Il•Ameri.c&D .,.... Wlu1t I I><Un-e eub. dsapter to be a ftlt im· ~ chtptu doll. nw.~. hu b<ltll I'N'-<Jf ~Ill tho IOutth 4ldlll<xQ, -lo. ~..., tMr COill!lbut!onJ .,. bu.ut! mr oplnlo~~o ~ opc<:W rcooenftlon. Ant}!..., fully .,;,a,(ei nt M cl! 1f""i"i dNI i .. with lise "1'1""'" WiboD, MD, ha, • hit finll """'"";. dlirrt, pn> dirnkr aldrtcm. So, DJ:. Pope is th< lopc&l dtoii:e pared liordt.ereaclao !Ito cloarat. -""""""'a o.d. to~Ttt.B.~vf~~ tho DIOft Ol!.dmt<U>dablt ~ of beth lilt inf llmre edition ~ clanificuioD d. oc:etabular fnomret &lld II i.t ~to rdlect tlolt iA tiLe turt editioo> of the l.o;opH&IueD cloHifi<atioA ofl llkle il>j"""' <Jf thlt booll, yobii.Z,od br Wt!Home and Wlll:illf IIIPt-tad. ill 1975, It <Cilta!Ded 14 ~ and ~~tuly 500 Chapur 4, "Fac:<,fndud!ng lntl1orblul Soft 'Itt ,..... The lint< hlpt<:ran the 'Ska11' comiltod of .... ...,d M&Ddiblt,• is011t d. aryfl""i:lo q>i<>&lld :U ~ c4" f!,romdnvttd to """'"Dtloa•l n. - whklil chmk I U...~ ..,Ulo. priot ~ <~lost.., <*tlle ebll.'nihld"'c nd> top!co ..t he tlonJ. Dr. Mad: ll<:m;1dn'a rcoiJ!oa <Jf 1IW cl!quf diJtiD<tiaD bmoa:D siNII fnw:mxa&Dd ........... th< hu ckn.tl:d lise bar <lf intc!!ed!!v sophimc11i011 ...n.r., ndiosnf~Uc ~<Jf lllo:illfnl:lw:a. wllilo, 11 t:bc- tim.e, (<OIIIjwi .. C>:o 1""""'1 die andmdlhodtof~I'I-'.IIWiddUp,_ lmaal•a ~ of tho «<mp~a. COD«Ptt <Jf ftlc:la1 an.a mm.t U &II>OIIifal.aiOD of U.:...Ued imn<rani&l --in • bl.cm~ ~le, pnomcal pmo"""' o:llliclliD< IIIUA. 1111'11S. ..........u~<m&J r..uoan,h, wu 11a.e pn. Dr. RI<IIU<! ~ tnitlo:o. of lise "Cetri<:a1 .,.., dlacnOftl< !0<11 <Jf the ~ ciq>art· Sp~De.• <:hap1<:r s. a ..., ._,,~ary csamp1c <lf """'' phylio:iaa ..ad whl1 frw rolltpa:WiJJI lllm: blrMi!>i blo"""'q!l ofa ::nial opill< iD}uri<s will!. wm tt that dmo. Auo, vuy frw cUDkal. ndl· mlD.t, wh!.:h han b«D. to:m.owlw tt ..atlaoct ont olosfeu ...,d ndlolock ,hy$!clt!t hill more thu th<.,._,.ln!l> • vadblonal!r O'q!lnlrod ...ct bcai· &11 ia'tlins of whit. the Nnlre of im•s,ins wouJct fally wrium chopt<:r. Dr. DaliD.er't miliaa thaola ....a.. b«OJDe iD the .21atceata.ry.1\Kliy. imaa'Giit tl:ae pNriilo II>< wid~. a cloat uilmi&Dd~<Jfdle ~<lfem<:fB<:Dt~....,.l,.t...aa n.ow«m1· <~ ofca•iolltp!a.c. III.CIIl, "'""',.ofm ultip!onar 111m0p A...,.~ pomi>. . aa.!itKm to the fiffh phy (MPCT) U.. o: adjac<DI to. the '"""""bay cdi1ioA i.t the <OatnlRIIioot ofo w JtOll·Ameri<u. and tho mlllablllty ofUPCT Ill tho mllo.tllo:o. of .audl«ttl; &llh.oo.ill tho im&IO* <Jf mo.tcWotbleW ,.11<:$, - -~ departm ...t Illa t trcma a« ~ tlmllu, th.elr c!etcrlpllo:o. II>< pali<At'a ddiDi:ti.ft diap..,;, it ealal>lioh<d o: ud =cient&DdiAs &om the uiqo.e Burope&ll ~. ... a bdo110 Jocv~aa tho~ l>ay or th< P~ pr<nidet ~ ma -..~o~W~y em.cra:=q d<portm<:Dt. (halleneJacre..U,.. 'lhr•ddftlon <Jfthe~ &iii