the case.
a 64 year old type-II diabetic presents to ED at 3am with ongoing severe knee pain & fevers.
pulling apart cases from the ED...
the case.
a 64 year old type-II diabetic presents to ED at 3am with ongoing severe knee pain & fevers.
the case.
a 2 year old male is carried into your ED screaming. He is horribly distressed and trying to reach down to grab at his right thigh. His parents report that he was standing outside watching his older brother ride his bike. He was knocked over in the process and his right leg ‘twisted around’ in the process. [Read more…]
the case.
A 34 year old insulin-dependent diabetic male presents to your ED following a “collapse” stating he thinks he has had a seizure. He has had hypoglycaemic seizures previously. He lost his glucometer 3 or 4 weeks ago and has been guessing his sugars and corresponding insulin doses by ‘how he feels’…
He has severe bilateral shoulder & upper thoracic pain. Any attempt to move, touch or examine either shoulder results in unbearable pain (plus a stream of four-letter expletives).
As part of his evaluation you get the following x-rays….
You are concerned about a bilateral posterior shoulder dislocation.
As we were unable to 100% decide whether these joints were in or out, we obtained a CT scan….
httpv://www.youtube.com/watch?v=V8atTnzhfKE
Right Shoulder:
Left Shoulder:
Posterior Shoulder Dislocations.
A rare event accounting for only ~2% of all glenohumeral dislocations. However, pay attention as this injury is missed in > 50% of initial presentations !!
Mechanics / Anatomy / History.
Clinically…
Radiologically…
Standard AP images can be deceptively normal whereas the lateral/scapular Y-view is diagnostic. Abnormal features include;
Management.
Complications of Posterior Should Dislocation.
Firstly, here are the 3D reconstructions from his CT.
This patients’ injury had actually occurred the night before his presentation (some 14-15 hours earlier). Taking this into consideration, and given his associated humeral fractures it was decided that the relocation attempt should take place in the OT with a general anaesthetic and full muscle relaxation.
Despite multiple attempts/techniques his shoulder could not be relocated.
He returned to theatre 48 hours later for an open-reduction and internal fixation.
the case.
a 19 year old female arrives to your resuscitation bay following a high-speed rollover MVA where she was the restrained passenger.
A joint decision with the Trauma surgeons is made; and we head to radiology for a pan-CT. This revealed the following…
httpv://www.youtube.com/watch?v=9B1YMOr9LK0&feature=youtu.be
What does the scan demonstrate…?
A flexion-distraction injury of the lumbar spine.
It represents failure of both the posterior and middle spinal columns under tension forces generated by flexion and distraction (from a fulcrum focus anterior to the vertebral body).
This is an unstable fracture involving all three spinal columns.
There is significant distractive disruption of middle & posterior ligamentous structures (50% of cases).
It is unusual, in that the fracture line extends through the spinous process, pedicle and into the vertebral body.
** Subtype of Flexion-Distraction Injuries – Image taken from Denis (1983) **
Most commonly associated with seat-belt injuries (especially isolated lap belts only).
This is often misdiagnosed as an anterior compression fracture.
Why is this injury so significant…?
Chance fractures are strongly associated with intraabdominal injuries. These result from rapid deceleration of intraabdominal contents against the lap belt, or compression against the anterior spine. There is also subsequent increased intraluminal pressure in hollow viscus structures.
CT scan is the preferred initial diagnostic modality of choice in the haemodynamically stable patient with a Chance fracture. It is however important to recognise its limitations particularly in the diagnosis of small bowel injury.
Remember to treat this injury like any other unstable spinal injury.
Our patient remained haemodynamically stable. Her MRI spine showed no evidence of epidural haematoma, canal or foramina narrowing. There was however ligamentous injury posteriorly, mainly at L1-2.
Whilst her mandible was repaired on Day 2, her splenic injury was managed conservatively.
This was her final operative repair prior to discharge home….
The Case.
A young boy is bought to your ED with an obviously swollen painful left arm after a slip and fall…
These are his xrays…
Type III Supracondylar Fracture, with posteromedial displacement.
Supracondylar Fracture – Tell me more…
The Gartland Classification.
An approach to the Paediatric elbow X-ray…
Firstly, we should recall the ossification centres of the elbow & the helpful mneumonic “CRITOE”.
taken from *http://www.wikem.org/wiki/Elbow_X-ray_(Peds)
The Anterior Humeral Line.
taken from *http://www.radiologytutorials.com
An abnormal anterior humeral line – taken from *http://www.radiologyassistant.nl/en/p4214416a75d87
The Radiocapitellar Line.
Fat Pads.
Adapted from wikimedia.org
Baumann’s Angle.
Left is normal. Right is obviously not...
Neurovascular compromise occurs in up to 49% of all Type III injuries.
Be on the lookout for Compartment Syndrome.
… well it wasn’t really a tonne; more like a dozen or so individual bricks falling from a height of 3-4 metres that peppered and glanced a patient I saw 48 hours ago.
Whilst he presented as a ‘trauma’ and was cleared of any significant injury, his greatest concern was his left ankle which was swollen and tender diffusely. He felt that as he was attempting to dodge the falling bricks, his ankle buckled and went under him (demonstrating an extreme plantar flexion mechanism with his good ankle).
These are two of his original xrays.