The case.
An obese 86 year old female is bought to ED by private car with a 5-6 day history of progressive dyspnoea and fevers. She is promptly rushed into the resus bay in extremis with cyanosis & poor respiratory effort. [Read more…]
no bones about it…
The case.
A 15 year old male is bought to ED by his mother with a complaint of throat pain after eating a meal of chicken skewers that were cooked on the family barbecue. He is alert and in no apparent distress, breathing comfortably without stridor or drooling. His observations are within normal limits and his chest is clear to auscultation.
The skewers were prepared at home from chicken breast and they “are pretty sure there were no bones around” ….
I ordered a CXR.
- Metallic-appearing foreign body in the superior mediastinum.
- Where is this ?!
- Most likely oesophageal given the history.
- It needs to come out ?!
- Gastroenterology agree & will review the patient, however they ask for a CT with the question “Has it caused any damage ?!”
Approximately 80% of swallowed FBs are in children (aged 1-4 years). This will involve toys & coins for example and will lodge in the anatomically narrowed parts of the oesophagus. Adult patients generally provide an unequivocal history but can occasionally present with unintentional ingestion (eg. dentures). Adult impactions tend to be more distal.
Signs & Symptoms.
- Throat or retrosternal pain.
- Localization of the object based on symptoms is rarely accurate.
- Dysphagia, vomiting, gagging.
- Children; refusal to eat/drink, vomiting, drooling, stridor, gagging.
Diagnosis.
- Plain X-ray can screen for radiopaque objects.
- Eg. Coins will face forward on AP films (generally face-on in lateral films for tracheal placement).
- Bones are only seen on X-ray < 50% of the time.
- CT is a high-yield test.
- Provides information on location as well as associated perforation or subsequent infection.
Management.
- Resuscitation [including airway protection with ventilatory & haemodynamic support].
- Aspiration risk with secretion buildup from complete obstruction.
- Emergent endoscopy is required
- Instances requiring urgent endoscopy;
- Airway compromise
- Sharp or elongated objects
- Multiple FBs
- Button batteries
- Potential for mucosal injury or necrosis & perforation.
- Two or more magnets.
- Evidence of perforation
- Coin at cricopharyngeus muscle
- FB for > 24 hours.
- Endoscopy allows removal of the majority of objects.
- Instances requiring urgent endoscopy;
- Indirect laryngoscopy or fibreoptic visualization may be helpful for proximal objects.
- Other techniques;
- Foley-catheter pulling object backs to oropharynx.
- Bougie to advance objects further into the stomach.
- Should only be used if object is blunt & lodged for < 24 hours.
- Glucagon:
- Controversial. No better than ‘watchful waiting’. Promotes unwanted vomiting.
- Objects beyond the pylorus…
- If shape or make is not of concern then treatment is expectant.
- If this is deemed inappropriate surgical referral must be made.
Sharp Object Ingestion.
- Need immediate removal (if proximal to duodenum)
- Intestinal perforation is common (~35%) when sharp objects pass distal to stomach.
- If object is distal to duodenum, then daily X-rays are required to document passage.
- Failure to pass object > 3 days requires surgical opinion.
- Concerning proximity of the FB to mediastinal structures.
- Appropriate surgical teams notified at time of endoscopy in case of vascular catastrophe.
- An uneventful scope takes place a few hours later with successful retrieval of a small metallic wire frond.
- It turns out the barbecue was rather dirty prior to cooking and the father had scaled off the old material with a wire brush (a dislodged frond had then made its way into/onto a chicken skewer).
Quick Case #01
A 24 year old male rugby player presents to your ED with a severely painful, swollen left hand which occurred during a tackle and subsequent ruck.
These are his x-rays….
Carpometacarpal Dislocation
- The carpometacarpal (CMC) joints form the base of the metacarpal arch of the hand.
- The metacarpal bases articulate with each other & with the distal carpal row.
- This is a complex structural configuration.
- Supported by volar, dorsal and interosseous ligaments.
- Reinforced by broad insertions of wrist flexors and extensors as well as the deep transverse metacarpal ligament.
- The ring & little finger MCs articulate with the hamate.
- These are more mobile and hence more susceptible to dislocation (5th >> 4th digit).
- Dislocations of the carpometacarpal (CMC) joints are rare.
- Often the diagnosis is missed.
- Most commonly a dorsal dislocation.
- Commonly associated with fractures.
- Clinically;
- Occurs as a result of MVAs, falls, crush injuries and closed-fist trauma.
- Marked swelling and deformity with pain over the dorsum of the hand.
- Thorough neurovascular examination is mandatory.
- Assess deep motor branch of ulnar nerve
- Passes adjacent to hook of hamate & can be directly injured.
- Beware of compartment syndrome.
- Radiologically;
- Fractures may be subtle on x-ray.
- Superimposed carpal & metacarpal bones.
- Extra-oblique films may be helpful.
- Management;
- Analgesia & limb elevation initially.
- Closed reduction can be attempted (following adequate sedation +/- regional anaesthesia)
- Traction & flexion with simultaneous longitudinal pressure on the MC base.
- Followed by extension of the MC head.
- Requires Hand-Surgeon referral & will likely need surgical fixation (K-wire).
- Volar dislocations are very rare and require Hand-Surgery involvement.
- Complications;
- Arthritis
- Weakness.
- Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- Wheeless’ Textbook of Orthopaedics
in or out ???
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….
- Bilateral humeral head/neck fractures
- Right glenoid fracture with drumstick appearance of humeral head.
- Left lesser tuberosity fragment.
- Both humeral heads appear posteriorly subluxed on oblique view.
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:
- Comminuted fracture of the head, anatomical and surgical necks of humerus involving both greater & lesser tuberosity.
- Fracture through posterior aspect of the glenoid.
- Mild posterior subluxation of articular surface of the humeral head relative to glenoid.
Left Shoulder:
- Comminuted fracture involving the head, anatomical & surgical necks of humerus.
- Cortical irregularity involving inferior aspect of glenoid ?non-displaced fracture.
- Humeral head is posteriorly dislocated and wedged on the posterior aspect of glenoid.
Posterior Shoulder Dislocation
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.
- A distinct mechanism of action is required to cause a posterior shoulder dislocation (forceful internal rotation with adduction).
- Lat dorsi, pec major & teres major overcome the smaller/weaker teres minor and infraspinatus.
- Convulsive seizures or electrocution have been associated with this injury (a direct blow to the anterior shoulder or falls can also produce posterior dislocation).
- Subdivided into subacromial, subglenoid & subspinous dislocations.
- 98% are subacromial.
Clinically…
- High index of suspicion based on mechanism.
- Pain is not very reliable
- Prominence of posterior shoulder w/ anterior flattening “squared off appearance”.
- Arm held in adduction & internal rotation.
- Inability to externally rotate.
- Abduction is severely limited.
Radiologically…
Standard AP images can be deceptively normal whereas the lateral/scapular Y-view is diagnostic. Abnormal features include;
- Loss of ‘half-moon’ elliptical overlap of humeral head and glenoid.
- “Rim sign”
- Increased distance between anterior glenoid & articular surface of humeral head.
- “Lightbulb” or “Drumstick” appearance of humeral head.
- Occurs due to humeral profiling in internal rotation
- Reverse Hill-Sachs deformity
- Impaction fracture of anteromedial humeral head.
Management.
- Urgent Orthopaedic consultation
- Closed reduction may be attempted
- Requires generous sedation & may be more appropriate for the OT.
- Axial traction is applied in the line of the humeral shaft, with gentle pressure applied on the humeral head. External rotation may help.
- ORIF may be required (+/- arthroplasty)
- Post-reduction:
- Shoulder immobilisation (minimum of 4 weeks).
- Orthopaedic follow-up.
Complications of Posterior Should Dislocation.
- Associated injuries include fractures to glenoid rim, greater tuberosity, lesser tuberosity & humeral head.
- Subscapularis may be avulsed from the lesser tuberosity.
- Neurovascular injury is rare (generally protected due to its anterior location).
- 30% of patients have recurrent posterior dislocation.
- Degenerative joint disease.
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.
- Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
in with a chance…
the case.
a 19 year old female arrives to your resuscitation bay following a high-speed rollover MVA where she was the restrained passenger.
- she has a clinically fractured mandible with some oropharyngeal bleeding, but a GCS of 15. she is able to use a yankauer-sucker and intermittently suction her own mouth. you are happy with her airway for now
- she is tachycardia at 125/min, and had a transient episode of hypotension (systolic of 85 mmHg) which resolved without intervention.
- with some analgesia her pulse settles to 110/min.
- her abdomen is exquisitely tender on the left side and she has a positive seat-belt sign.
- she has free fluid on FAST exam (LUQ)
- she has midline spinal tenderness in the upper lumbar region…
A joint decision with the Trauma surgeons is made; and we head to radiology for a pan-CT. This revealed the following…
- Mandible fracture.
- Splenic laceration
- and this….
httpv://www.youtube.com/watch?v=9B1YMOr9LK0&feature=youtu.be
- Acute L2 Chance-type fracture.
Chance Fracture.
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).
- The anterior column may partially fail (under compression, acting as a hinge) or may completely disrupt (hinge failure).
This is an unstable fracture involving all three spinal columns.
There is significant distractive disruption of middle & posterior ligamentous structures (50% of cases).
- Typically interspinous ligament, ligamentum flavum, facet capsule, posterior annulus & thoracodorsal fascia are involved.
- The other 50% result from fracture through bone.
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).
- Also associated with pedestrian-vs-car injuries and falls.
This is often misdiagnosed as an anterior compression fracture.
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.
- Associated intraabdominal injuries.
- Small bowel
- Spleen
- Large bowel
- Kidney
- Pancreas
- Omentum & mesentery
- Liver
- Stomach
- Adrenal glands
- Large vessel.
- Hollow viscus injury occurs in ~22% of Chance fractures.
- However; in patients with identified intra-abdominal injuries, 65% have hollow viscus injury.
- Have high index of suspicion for more than one injury.
- Abdominal wall contusions (“seat-belt sign”) in combination with Chance fracture is very suggestive of intraabdominal pathology (50-68%) and increased need for laparotomy (50-72%).
- The absence of abdominal wall contusions drops the likelihood of intraabdominal pathology and need for laparotomy to 14% & 9% respectively.
- Spinal cord injury may accompany up to 25% of Chance fractures.
- Associated with high-grade posterior element dissociation.
- Abdominal aortic injuries (particularly dissection) have been known to occur in paediatric trauma patients with Chance fractures.
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….
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- Current Diagnosis & Treatment: Surgery, 13th Edition.
- Wheeless’ Textbook of Orthopaedics.
- Denis, F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine 8(8), 817–831.
- Tyroch, AH et al. The association between Chance fractures and intra-abdominal injuries revisited: a multicenter review. The American surgeon, 71(5), 434–438.
- Chapman JR et al. Thoracolumbar Flexion-Distraction Injuries: Associated Morbidity and Neurological Outcomes. Spine (Phila Pa 1976). 2008 Mar 15;33(6):648-57.
- Inaba K et al. Blunt abdominal aortic trauma in association with thoracolumbar spine fractures. Injury. 2001 Apr;32(3):201-7.
- Choit RL et al. Abdominal aortic injuries associated with Chance fractures in pediatric patients. J Pediatr Surg. 2006 Jun;41(6):1184-90.
slip and fall…
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
- The most common paediatric elbow fracture.
- Typically occurs in kids < 8 years of age.
- This is a result of the ligament/joint capsule tensile strength being greater than that of the bone itself.
- Extension vs Flexion:
- Extension:
- >95% of all supracondylar fractures are extension related.
- Olecranon forcefully driven into olecranon fossa.
- Results in failure of anterior cortex & displacement of distal fragment posteriorly.
- Can be further defined by the Gartland Classification.
- Flexion:
- Energy transferred from posterior aspect of proximal ulna to distal humerus.
- Anterior displacement of the distal fragment and failure of cortex posteriorly.
- Extension:
The Gartland Classification.
- Type 1: Non-displaced.
- Type 2: Displaced fracture with intact posterior cortex.
- Type 3: Displaced fracture with no cortical contact.
- A: Posteromedial rotation of the distal fragment.
- B: Posterolateral rotation of the distal fragment.
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.
- On a normal lateral elbow x-ray, a line drawn along the anterior surface of the humerus should pass through the middle third of the capitellum.
- If the capitellum falls posteriorly to this line, an extension-type supracondylar fracture is likely…
taken from *http://www.radiologytutorials.com
An abnormal anterior humeral line – taken from *http://www.radiologyassistant.nl/en/p4214416a75d87
The Radiocapitellar Line.
- A line drawn along the radial neck should intersect the capitellum.
- Failure to do so, suggests a radial head dislocation.
- For great examples see RadiologySigns – Three children with elbow pain… or Radial Head Dislocation @ Youtube.com
Fat Pads.
- An anterior fat pad protrudes from the Coronoid fossa.
- It is normal unless bulging or shaped ‘like a sail’.
- A posterior fat pad is always pathological.
Adapted from wikimedia.org
Baumann’s Angle.
- An additional aid for diagnosing subtle supracondylar fractures.
- Angle is formed by a line drawn along the growth plate of the capitellum that transects a line running along the axis of the humerus.
- It should be ~ 75 degrees.
Left is normal. Right is obviously not...
Neurovascular compromise occurs in up to 49% of all Type III injuries.
- Median nerve:
- Involved in 50% of cases.
- Associated with posterolateral displacement.
- Radial nerve:
- Involved in 1/3 of cases.
- Associated with posteromedial displacement.
- Brachial artery:
- Includes entrapment, laceration, intimal tear or compression (compartment syndrome).
- Approximately 40% of cases.
- Found in either medial or lateral displacement.
Be on the lookout for Compartment Syndrome.
- Pain on flexion or extension of fingers
- Forearm tenderness on palpation.
- Disproportionate pain to injury.
- Important as unrecognised ischaemic injury can result in Volkmann’s Ischaemic Contracture.
- Obviously, a limb with neurovascular compromise mandates immediate reduction.
- Delay to the operating theatres may require a reduction attempt in the ED. Rosen’s demonstrates this manoeuvre quite well.
- Type I injuries;
- Splint in ED (aim for 90 degrees of elbow flexion, with neutral rotation).
- Outpatient referral to Orthopaedics is appropriate.
- Type II injuries;
- No current consensus with regards to surgical management.
- Closed reduction & plaster vs ORIF.
- Referral to Orthopaedics at let them decide.
- Type III injuries.
- Urgent Orthopaedic consultation –> OT for closed reduction, pinning or ORIF.
- Splinting for comfort.
- Thorough and repeated neurovascular examination.
- Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
- The Royal Children’s Hospital Melbourne; Clinical Practice Guideline on Supracondylar Fractures.