CIP Case of the Month

Traumatic Fractures. Submitted by Todd W. Cramer, MD, and Arun R. Krishnan, MD.CIP case of the month

November 2012's most popular Case in Point (CIP) submission, as chosen by CIP users, was "Traumatic Fractures." The case followed the management of a 56-year-old man who suffered a cervical spine injury after falling from a bicycle.

The submission was lauded by users as a "very practical and useful case" that showed "all potential findings of cervical spine trauma on MRI." The ACR Bulletin spoke with Todd W. Cramer, MD, lead author and resident at Emory University Hospital in Atlanta about traumatic injury and CIP submission.

Q: Why did you select "Traumatic Fractures" for submission to CIP?

A: I came across this case in a teaching session with Arun R. Krishnan, MD, my faculty mentor for this submission. This case helped me understand several common consequences of blunt cervical spine trauma, and my hope was that others might find it useful as well. Unlike a slow-growing tumor or unusual anatomic variant, the near-immediate, accurate diagnosis of epidural hemorrhage, ligamentous injury, and arterial occlusion is essential for the care of a traumatized patient. These are "don't miss" diagnoses that should be shown to trainees, probably several times, before they encounter such injuries in practice.

Q: Describe your thought process as you were preparing your case for submission.

A: I wanted to walk through the findings in the same order that trauma exams are typically obtained, so I showed first the CT, then the MRI, and finally the CTA. In actual practice, additional studies should only be obtained if the radiologist or clinician has evidence that the additional tests are warranted. In this case, the CT findings prompted the MIR, and the MRI prompted the CTA. If all three exams were shown at once, readers would not be led to decide whether they would have recommended the next test. Particularly in this era of cost containment and concerns about diagnostic radiation exposure, radiology training should include learning how to recognize when additional imaging is warranted and how to select the most appropriate next test.

I also hoped to show how traumatic injuries can be overlooked by over-reliance on cervical spine radiographs. Fortunately, our emergency medicine colleagues had a high index of suspicion after examining the patient and proceeded straight to cervical spine CT. Although there were extensive soft tissue and vascular injuries, the bony abnormalities were subtle, and I suspect they could have been overlooked had only radiographs been obtained.

Q: Some of our users commented that it was nice to see a trauma case. How does the inclusion of trauma improve CIP?

A: Not all radiologists have the opportunity to serve a level 1 trauma center. I suspect that those who found this case most useful encounter a low volume or acuteness of trauma in their day-to-day practice. I hope that this case provides them with findings that they can incorporate into their search pattern when evaluating patients who have suffered cervical spine trauma.

Q: Since ACR introduced the Case of the Month series, over half of the winning submissions have been neuroradiology cases. What do you think accounts for the popularity of this topic?

A: Neuroradiology is a tough subspecialty to conquer. There is so much to know that the subject easily becomes overwhelming. CIP cases break the field into more manageable pieces that can serve as jumping-off points for further reading.

Q: Are you a regular reader of CIP? What are your favorite types of cases?

A: I am a regular reader. I especially look forward to cases that show unusual presentations of a common disease process. I also like to learn from submissions that review common pitfalls in image interpretation. I would much rather fall into a common trap while reviewing a CIP case than while sitting in front of the workstation.

Q: Why should radiologists take advantage of CIP?

A: CIP broadens awareness for radiologists. Unlike many textbooks and case files, CIP draws from a worldwide pool of authors. The types of diseases we see and therapies we employ at our own institutions are only small slices of the cases encountered by our colleagues across the globe.

"Traumatic Fractures" was published on November 16, 2012. To view the full case, visit

By Anastasia Simkanin
Anastasia Simkanin (This email address is being protected from spambots. You need JavaScript enabled to view it.) is the CIP manager for the ACR Education Department.

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