Category Archives: xrays

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