Category Archives: Radiology

Paediatric Hip Pain

So you have a toddler/child/adolescent complaining of a sore hip and limping in your clinic? What are the different causes, how can you differentiate between them and what do you do from there? Watch on!

Online resources:

Acutely Swollen Joint Flow-chart

RCH guidelines for Acute Hip Pain

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January 14, 2013 · 11:37 am

Finger dislocations and auto-irradiation

Doctors are trained to diagnose and treat conditions that patients come to them with. But what happens when the doctor themselves are unwell? Discussions with colleagues often reveal stories of self-prescription and treatment. Usually, this is limited to antibiotics and regular medication use. Recently, I was confronted with a self-treatment situation as a GP registrar in my 2-doctor country town.

Now where was that ureter?

Now where was that ureter?

However, the precedent for medical practitioners treating themselves is not a new one. In 1961, Leonid Rogozov performed surgery on himself as the only doctor on an isolated Russain Antarctic station. He recognised the symptoms of appendicitis and dutifully performed an auto-appendicectomy. Luckily he had the equivalent of surgical interns helping, a driver and meteorologist holding instruments and a mirror.

Alas, my story is not as hardcore.

"just some tape will do"

“just some tape will do”

It was the fourth round of Mid West football in country SA and I was lining up on the wing for the Wudinna United B grade team. Even though the two teams playing were bitter rivals, first quarter went by without incident. However, halfway through the second quarter, I went to punch the ball coming down into a pack of players. As my 2nd finger hit the Sherrin, there was a pop then numbness. Looking down at my right hand it was obvious that I had dislocated the proximal interphalangeal joint. Luckily, I was able to easily reduce the finger as soon as it happened. There was surprisingly little pain, perhaps the adrenaline was covering that? A trainer had seen me holding my fingers and came over. “What do you want to do doc?” And I thought they were the experts! I had seen enough jarred fingers in the city emergency departments to get something started. Some tape did the trick in buddy strapping to my middle finger and I grabbed a couple of ibuprofen. At half time one of the other trainers sidled over and looking at my two fingers strapped together said, “hope you’re not offended if I cancel my rectal exam this week mate.”

Still getting a touch while crippled...

Still getting a touch while crippled…

Better than the iPhone x-ray app

Better than the iPhone x-ray app

Back at the hospital, I took my own x-ray and interpreted the film. No big or intra-articular fractures….that I could see anyway. Perhaps just a slight little chip off the volar aspect of the base of the middle phalanx (left, happy for radiology comment!!). Certainly not enough to warrant anything to drastic as far as surgery went. So I decided that the management should be continued continued as RICE and NSAID-based analgesia. But it made me wonder, if in my post game haze, I had followed proper treatment of finger dislocations for this injury? Certainly I had seen cases in ED where you could always ask for a ortho/plastics opinion. But in the country this isn’t as easy. So what would have been the indications to get my x-rays and finger looked at properly. Next week, I will discuss the equipment and alcohol necessary to take out your own appendix*

Lead shield in place?

Lead shield in place?

Searching around, I found some quick points regarding proximal interphalangeal joint (PIPJ) dislocations:

  • Vast majority are dorsally dislocated
  • Caused by direct blow (usually a ball) to the tip of the finger (axial load)
  • Put in ring block if reducing in ED, but patient can try to self reduce easily as soon as it happens
  • Reduced by slight traction and pressing on the distal end of middle phalanx
  • Murtagh suggests holding onto the distal finger and asking the patient to lean backwards
  • Ortho/plastics referral may be required if
    • Lateral instability
    • Fractures involving base of middle phalanx
    • Extensor mechanism rupture – buttonhole or mallet finger deformity
  • If no worrying signs: buddy strap to adjacent finger for 3-6 weeks to avoid hyperextension

*Fortunately, prospective Antarctic doctors now have a prophylactic appendicectomy.

Ouchy

Ouchy, but not my finger. Same injury

References:

  1. Murtagh’s General Practice
  2. Roberts and Hedges, Clinical Procedures in Emergency Medicine

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Filed under #FOAMed, Emergency Medicine, General Practice, Radiology, Rural GP, xrays

Butterflies in the stomach

Swallowed foreign objects in kids

I was called to see a poor young fella up at our country hospital the other week and the case got me thinking about the above topic. As we all know, kids are delightfully inquisitive and adventurous. Of course Freud provided us with the five psychosexual development stages. The oral stage is first and spans from birth to around 21 months of age. Unfortunately this stage coincides with the period in which children become increasingly mobile and can evade the watchful eyes of parents. It follows then that the risk of objects being swallowed also increases. (Interestingly, our ED collueges tend to see many adults stuck on the 2nd and 3rd psychosexual stages presenting with interesting radiological findings….)

However a large observational study in 1999, found that the mean age was 5.2 years (Cheng, Tam; 1999). Although many objects will pass through unobstructed, there are a few cases in which emergent care and/or watchful waiting must be undertaken. Like any medical problem a proper history, examination, investigation and treatment plan is required.

History

The primary objective is to glean what the foreign body is and when it was ingested. Sometimes this isn’t always obvious as the parent was not present at the time. An important strategy is to bring a replica of the object. Especially when dealing with lego, disc batteries or hair clip if possible. Any reports abdominal pain or blood in the stool is important. A history of developmental or intellectual delay can also be associated with major complications given a delay in presentation and vague symptomatology. This extends to adults with such disabilities and should always be considered in any case of abdominal pain in this population.

A list of commonly swallowed objects:

  • Buttons
  • Bones (chicken, fish)
  • Coins
  • Keys
  • Safety pins
  • Drawing pins
  • Lego
  • Glass
  • Soft drink lids
  • USB sticks

Special cases:

  • Large coins (ie 20 and 50 cent pieces)
  • Hair clips
  • Button/disc batteries
  • Magnets

Examination

The demeanour of the child may provide hints as to how far the object has progressed. A child with an oesophageal foreign object may be in distress, vomiting, drooling, and irritable or refusing oral intake. Those with objects in the stomach conversely, may be asymptomatic. However these presentations are not the rule and further investigations sought. Palpation of the abdomen can be normal, but signs of peritonism or localised tenderness point to perforation. Generally, examination will be unremarkable.

Investigation

Plain x-ray (XR) is indicated for any metallic foreign objects. The role of XR is to demonstrate that the foreign object has passed the oesophagus. In this case, the object will be below the diaphragm in the stomach. Mouth to anus imaging is usually required.

Nasty battery, luckily in the stomach (NB fluoro light reflection, not chest tube!)

Treatment

Disc batteries

The alkaline nature of these batteries (used in watches and hearing aides) can erode tissue when in contact with moist mucous membranes. If stuck in the oesophagus as seen on XR, these should be removed urgently or the child retrieved to a centre that can perform endoscopy. The tissue destruction can occur in a matter of hours. On the other hand, asymptomatic children with subdiaphragmatic batteries can be observed at home. The stool must be searched and a repeat XR performed after 3-4 days if it has not passed.

Coins & Hair clips

If the offending currency/clip reaches the stomach, there is usually no treatment or intervention required unless symptoms arise. If the agent is stuck in the proximal or middle oesophagus, then semi-urgent endoscopy is required. Although they lack the chemical effect of disc batteries, they can still cause pressure necrosis and perforate. Distal oesophageal objects can be observed with follow up XR. Check stool for passage.

Magnets

The most important question apart from those covered above are: what sort of magnet and how many were swallowed. Recently, there has been a growing trend of ingested strong magnets causing perforation, obstruction and even fistulae. Fatal attraction indeed. So magnets may need urgent surgical intervention even below the oesophagus.

Humorous stories

A young man that I went to college with had skolled a pint of beer at a pub night that had a dollar coin at the bottom. When he presented to ED that night, the coin was found to be subdiaphragmatic. Palpation over the stomach was performed asking “are we on the money here?” and the patient was sent home to ‘pass the buck.’

Not so shiny anymore…

I saw the poor young girl in ED in late 2011, above, who had on her birthday accidentally swallowed her shiny new hair clip and inadvertently got butterflies in her stomach. I didn’t follow up as to whether she was given a replacement.

Another comes from Dr. Scott, my affable GP supervisor had this gem on hand:

God speed, little pendant

Dear Doctor,
‘James’ was brought into A&E this afternoon after swallowing a St Christopher medallion.  We x-rayed him and confirmed that this had passed the diaphragm. We have reassured the parents that the medallion should pass with time and without complication.  We have, however, advised them to see you or represent here should St Christopher’s own travels be unduly delayed.
Sincerely,
A&E Consultant

Final pearls of wisdom:

  1. Find out what it was and when it was swallowed
  2. Foreign bodies in the stomach or intestine should pass in 99% of cases (with normal anatomy)
  3. Most complications involve foreign bodies in stuck in the oesophagus
  4. Plain x-ray can localise a metallic foreign body and stratify into oesophageal and subdiaphragmatic
  5. Caution with disc batteries!

References: 

Murtagh, J. (2008) John Murtagh’s general practice.  (4th Edition). Sydney: McGraw-Hill Australia.

Cameron P, et al. (2012) Textbook of paediatric emergency medicine. (2nd Edition). Sydney: Elsevier.

Cheng W, Tam PKH. Foreign body ingestion in children: experience with 1266 cases. J Pediatr Surg 1999;34:1472-6.

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Filed under #FOAMed, Emergency Medicine, General Practice, Humour, Radiology, Rural GP, xrays

Situs Inversus

A 50 year old lady presented to our tertiary hospital with abdominal pain of a non-specific origin. It was decided by the ED consultant to order an abdominal CT scan (otherwise known as a ‘grope-a-gram’). Although there was no obvious pathology detected to explain her symptoms, I was still showed the abdominal slices to look for an interesting finding:

“Who is the fairest of them all?”

I will post a short precis on this condition (and its classification) in a few hours leaving some for the Twitterverseto have a gander. I wonder how long it takes you to find it, I remember it being well over 30 seconds for me!! ===============================================================

So after my almost minute of searching through the above grey/white/black image for subtle fat stranding, flaps of aortic lining and pancreatic abscess, it hit me. “Oh s**t. The liver isn’t supposed to be on that side.” My heart sank when a medical student came up and said straight away “this CT looks weird” and without missing a beat exclaimed “everything’s on the wrong side.” A few terms of colorectal surgery and general medicine had me looking for minutia. I’d failed to see the forest for the trees, or leaves even! The more thoracic slices were easier to pick:

Put your hand on your heart….other side please

What we had was a case of situs inversus. This condition can also be known as situs transversus, situs oppositus or situs organsaroundthewrongwayus*. Their internal organs are mirrored across the sagittal plane, or more simply: things usually on the right side of the body (liver, gall bladder, caecum) are found on the left and vice versa.

*Term made up by me, just now.

So what is the first thing you should think of when you see a CT like this? No the answer shouldn’t be situs inversus. Common things happen commonly. Mislabelling or image mirroring of the CT may be to blame. Then if you are confident this is not the case, time to delve into the rarefied air of such genetic abnormalities. Rare, yes. But the classification of position of internal organs is quite simple. It is not clearly essential knowledge, however very good for impressing cerebral physicians…

Total flips of the heart

  • Situs solitus (‘normal’) – How most of us and the anatomy text books are put together/drawn
  • Situs inversus with dextrocardia (situs inversus totalis) – Most common form of inversus which has a right sided heart, in keeping with the switch
  • Situs inversus with levocardia (situs inversus incompletus) – A much more rare form of an already rare condition in which the heart remains on the left (normal) side of the thorax
  • Situs ambiguous (heterotaxy syndrome) – Any combination of the above that does not fit a pattern of complete solitus or inversus. Calling it ‘incomplete’ situs inversus probably explains it better, but sounds too much like the latter.

Basically your insides are all topsy-turvey…

Situs inversus is thought to have a prevalence of 1 in 10,000 people. It is inherited in an autosomal recessive manner and is usally associated with other congenital heart defects (most commonly transposition of great vessels, TGV). Interestingly, although Leonardo Da Vinci was the first to describe dextrocardia, it was Matthew Baillie who described situs inversus and TGV. He was a Scottish physician who in 1793 wrote the best titled text I have come across: The Morbid Anatomy of Some of the Most Important Parts of the Human Body.

Interestingly 25% of patients with situs inversus have an underlying diseased called Primary Cilia Dyskinesia (PCD). Cilia are tasked with placing organs in their appropriate positions during embryogenesis and this is where things can go wrong. If patients have the triad of chronic sinusitis, bronchiectasis and situs inversus, then this is known as Kartaneger syndrome. Perhaps its worth conducting a thorough listen to the chest (or ECG) for those patients with recurrent sinusitis and mucousy coughing?! These conditions pose interesting anomalies, but what are the practical consequences for the patient sitting across from you?

  • ECG interpretation: If you attach the leads (correctly!!) and see strange axis deviation, p-waves inversions and a decrease in QRS voltage across to V6, then there may be inversus. To confirm this, swap all of the leads across to the right chest, including limb leads. The lesson though, is always double check lead placement lest you end up diagnosing ‘technical dextrocardia’

RA lead goes on the left lower limb?

  • General surgery 101

    Pain/Tenderness: We are taught in surgical training to know that for pain or tenderness in the abdomen, think about the underlying structures to help differentiate causes. Clearly if things are mirrored it will change your thinking. LIF pain could be appendicitis, RIF pain could be sigmoid diverticulitis and LUQ pain could be gall bladder related. Bruising over the right flank might mean you are worried about a splenic rupture.

  • Organ transplantation: The vast majority of organ donors will have anatomy orientated in the usual way. However if a patient with situs inversus needs a transplant, problems arise. Not only are arteries and veins in different positions, but the physical shape of the organs will not match up. In fact, an American patient with situs inversus underwent a heart transplant in 2007. The six-hour long operation was likened to solving a “three dimensional Rubix cube” (actually not sure what other dimensions Rubix cubes come in…but here is one solved in 30 seconds)

Thanks for reading and contributing. Clearly this is not a common presentation or finding, but hopefully if you happen across an interesting CT, CXR or ECG, you will have some background knowledge of these rare and fascinating disorders.

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Filed under Emergency Medicine, General Practice, Radiology

Tales from the Wudinna Radiology Department

In Soviet Russia, x-rays take you!

Ok, so I’d better make it clear. The “Radiology Department” in Wudinna consists of four radiographers. That’s a GP, GP registrar (me), the Director of Nursing and the CNC. The radiographs are taken in the A&E and then developed in an old broom cupboard with a fan. I thought that I would reflect back after taking my 20th x-ray tonight. It has been almost 3 months since completing the course that enabled us rural registrars to fire off energized photons into the atmosphere. My first x-ray (below) was of an old bloke who’d fallen onto his hand. I know now that I should have asked about any previous damage/operations to that wrist….”sorry, where exactly did your scaphoid bone go?!?”

Complete with adamantium rods and screws

This blog will document some of the good, bad and ugly radiographs that I have taken for educational purposes. It may also prove to be a repository of settings and views to call back on in the future.

Would hate for Mr. T to need a CXR

So first up some tips I have learnt/gathered over this time (updated as required):

  • Only a brave radiographer packs away the x-ray machine prior to developing the film.
  • Take off all jewellery from the patient. Think also about watches, phones, metal zips and buckles, forgot for my first CXR (right)
  • Always load fresh film into the cassette as soon as the exposed film is removed, nothing worse than taking an x-ray with a filmless cassette.
  • With 15 room changes of air per minute, the developing room is the best place to fart.
  • Don’t take the developing room/film cupboard key home with you.
  • Label your film with patient name, DOB, body part and put L/R markers on.
  • Check for pregnancy, always use gonad shielding for patient and lead apron/lead shield for yourself (don’t want children looking any more strange than they already will).
  • Make sure the collecting hopper is clear of previous x-rays
  • DON’T TAKE THE KEY HOME, GERRY!!

Today one of the films came out completely black. Stunned at the first x-ray that hadn’t worked out, I tried to remember the five reasons for such an occurrence (but had to look them up again):

  1. Film overexposed
  2. Processing times too long
  3. Ambient temperature too warm
  4. Film exposed to another light source
  5. Red safelight in developing room cracked

Checklist: the right settings were used, the machine was set up the same, the day wasn’t super hot and the film hadn’t been opened or exposed to white light. What had happened? So like any good doctor or engineer, or possibly any male, I took the x-ray again without changing anything! This time when putting the second film through the machine, I realised the first one had only just come out. The black film I’d pick up initially was a test film that had been run the day before by someone else and left in the hopper for an unsuspecting registrar. Another tip!

At least these guys got my name right!

When it comes to evaluating a film there is a helpful acronym (PACEMAN) that radiographers often use for quality control. Note that this is not to do with interpreting an x-ray for diagnostic purposes, its more about working out how to improve the actual picture.

  • P – Position
  • A – Area covered
  • C – Collimation
  • E – Exposure
  • M – Marker
  • A – Aesthetics
  • N – Name and DOB

So an evaluation of an x-ray make sound like “this is an AP view of a tib/fib. The ankle through to the knee is visible and collimated to the skin edges. The film is possibly a little over exposed, but good bony detail seen and the film is otherwise diagnostic. There is a left marker in place. The leg is lined up well on the film and the name/DOB have been removed for confidentiality.” It is important to think about the exposure especially as you may need to repeat the film and change the settings accordingly.

Fingers usually don’t bend between knuckles…

At the moment, Wudinna like many other towns around SA, use x-ray film and an automatic developing machine to produce images. Crystal Brook still has the old, old, old school method of manually dunking the film in each step of the process with a timer to help. Computed Radiology (CR) is a method of producing x-ray images straight to computer without film. This technology has been used at the major hospitals in the city for a few years now. Soon CR will be available at most small country hospitals in South Australia (already available at Jamestown, Ceduna and others?). This will certainly improve the quality of film, speed of referral and even the accuracy of reporting. Although there is a high initial cost for the system, running costs are vastly reduced as there is no need for ongoing purchase and disposal of hazardous chemicals or film. It will also mean that I can stop using the hospital camera or my iPhone for taking pictures for this blog and/or my friendly orthopaedic surgeon in Whyalla.

If you have any further pearls/gems/basic tenets of rural radiography…please comment!

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Filed under Emergency Medicine, Radiology, Rural GP