UCONN Emergency Medicine Interest Group

Posts Tagged ‘orthopedics’

EM Images #8

In IMAGES on November 6, 2011 at 7:00 AM

Syndicated from the UCONN EM Residency website; credit to Dr. London for images and text.

These three people all have the same condition, which can be diagnosed bedside. Note all three have extremities that are fixed in the position in which you see them. These arms can not be moved by active or passive range of motion.
The first, an older woman, and the third, a younger man, were pedestrian versus car with outstretched hands at the moment of impact. What do they have and how do you fix it and what special considerations accrue to such a diagnosis? (click below to see answers and explanation)

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EM Images #4

In IMAGES, RADIOLOGY on July 2, 2011 at 11:38 AM

Syndicated from the UCONN EM Residency website; credit to Dr. London and Dr. Bolton for images and text.

AP (left) and lateral (right); click to enlarge

Click to enlarge

The patient is a 62-year-old female who yesterday suffered a fall from a standing height when she slipped on her kitchen floor feeling immediate pain in her left knee. She felt pain in no other area. She was able unable to get herself up, but her husband showed up shortly after she fell and helped her to the couch. She was brought by ambulance to the ER this morning for evaluation of her left knee. She was having no previous fevers, chills or sweats. There has been no back pain, chest pain or shortness of breath. She has had no previous injury to the left knee. She has joint-line tenderness laterally in the left knee. She has good range of motion from about 100 to 110 degrees from full extension. She does not tolerate the exam to varus or valgus stress secondary to pain. Similarly, she does not tolerate the anterior-posterior drawer, Lachman’s secondary to pain. She has no pain to palpation along her back or neck.

PMH: HIV, HTN, asthma, depression, anxiety.

PSH:
1. Left hip ORIF versus hip replacement (the patient is unsure which); she fell and broke her hip a few years ago and was treated at New Britain Hospital.
2. Right ankle ORIF for a fall similarly.

Medications: 1. Truvada. 2. Reyataz. 3. Norvir. All are for her HIV. She does have asthma but no longer takes medication for this.

Allergies: Percocet, which causes itching.

SH: 3 cigarettes a day x 30 years. ETOH occasionally. Denies IV drug abuse.

FH: noncontributory.

Plain films were ordered, which you can see at the top of the post; the reading is as follows:

Clinical Indication: Pain and swelling. Four views of the left knee show no evidence of joint effusion there is there is osteophytic spur arising from the lateral tibial plateau but no definite fracture is seen. Alignment is generally anatomic except for some minimal degenerative change. No other significant findings are seen.

What is the likely diagnosis? What would you do next? (click below to see answer below the fold)

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Journal Article Synopsis: Bedside Ultrasound for Pediatric Long Bone Fractures

In JOURNAL CLUB on June 13, 2011 at 11:00 AM

Summary for “Bedside Ultrasound for Pediatric Long Bone Fractures ” by Keith Cross in Clinical Pediatric Emergency Medicine Vol 12 (1); pp 27-36

What is already known on this topic:
Almost all suspected fractures are currently evaluated by radiographs, with fractures requiring reduction often requiring multiple radiographs and/or fluoroscopy. Bedside ultrasound may provide an alternate imaging modality with advantages of decreased radiation exposure, identifying occult fractures in young children with poorly ossified bones, and use in austere conditions without ready access to X-rays.

What question this study addressed:
Can bedside ultrasound be used in pediatric patients with suspected long bone fracture to diagnose fracture accurately?

Which long bone fractures have the best evidence for ultrasound diagnosis?

What was the study design:
Brief reviews of several studies for diagnosis of radius/ulna injuries and fractures, reduction of forearm fractures, humerus injuries, clavicle injuries, femur injuries, tibia/fibula injuries. The technique for identifying long bone fractures by ultrasound is described with recommendations on transducer choice and imaging settings.

What this study adds to our knowledge:
Sensitivity and specificity for diagnosing pediatric long bone fractures was high for a wide variety of suspected fractures. One study demonstrated highest accuracy for simple fractures of the femur, humerus, and forearm bones, and lowest accuracy for compound fractures, small bone fractures, and Salter-Harris type I injuries. Several studies showed ultrasound-guided forearm fracture reduction was very frequently successful on first attempt. Diagnosis of proximal and midshaft humerus fractures has good evidence; diagnosis of supracondylar fractures has less evidence and may be more challenging. Diagnosis of clavicle fractures has excellent evidence and may be suitable as a primary imaging modality, and offers the advantages of avoiding radiation to thyroid tissue. Femur fracture diagnosis currently has limited evidence, but some case reports and case series suggest it may be feasible for midshaft fractures. Tibia and fibula fracture diagnosis also has limited evidence, and the largest study thus performed shows a lower sensitivity for identification of these fractures.

The author recommends using a 10 to 15 Mhz linear transducer with the vascular preset setting. Fractures may be identified as a disruption of the echogenic line of cortical bone, a hematoma over the bone at the point of fracture, an avulsed bone fragment, or callus formation appearing as a hypoechoic mass around the bone.

How this is relevant to clinical practice:
Ultrasound diagnosis may be a more rapid and less painful way to diagnose some pediatric fractures with less radiation exposure and potentially less time required and decreased pain to the patient, particularly for forearm and clavicle fractures.

Other considerations:
Many of the studies were performed by radiologists or orthopedists as the sonographers; it would be helpful to see more studies using emergency physicians as the primary sonographers.

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