Case. Case 8/29/ yo man with fever, cough. Vitals: Temp 102, HR 130, RR 20, bp 120/80. Ill appearing, crackles R side chest. Now what?

Transcription

1 Kate Aberger, MD August 28, 2016 Help from : Raphael Brancato DO, and Jordan Jeong DO Case 56 yo man with fever, cough Vitals: Temp 102, HR 130, RR 20, bp 120/80 Ill appearing, crackles R side chest Now what? Depends.. On what? Case Where are you? What is his follow up? Underlying disease? 1

2 Principles When to order What to order Why to order How will the study change your management? Radiograph facts Approach to interpretation Cases Principles Anatomy and Physiology is key Remember the body is 3 dimensional BUT... Radiographs are 2 dimensional and shades of grey Depicts densities 2

3 Principles Difference between diagnosis and reading Pneumonia = Diagnosis Right Middle Lobe Infiltrate = FINDING When in doubt, describe exactly what you see Lucency, opacity, density etc Basics Radiopaque = Doesn t allow passage of rays through high absorbency only a little bit gets through results in white color Radiolucent = Permits the passage of rays through low absorbency most of the rays get through resulting in dark image What is it? ABSORPTION = tissue absorbs x ray beam to differing degrees TISSUE: Air = Black Fat = Dark Gray Soft tissue = Gray Bone/Calcium = White 3

4 Rules of Two Views one is too few Abnormalities look for a second abnormality Occasions always compare with old films Visits repeat films after procedures Opinions ask colleagues opinion Records document clinical and radiologic findings Examinations not satisfied? Consider US, CT, MRI AGAIN Treat the Patient not the radiograph H and P before ordering Order radiographs only when necessary Look at the patient AND the radiograph Look at the whole radiograph Re examine the patient if unsure Remember the rule of 2 s Fail safe measures in place 4

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9 Before you interpret POPIRAM P: Projection, PA or AP, left or right lateral? O: Orientation, L or R side of xray P: Penetration, under or over I: Inspiration R: Rotation A: Angulation M: Motion 9

10 AP vs PA Orientation 10

11 Penetration Penetration 11

12 Inspiration Inspiration cont 12

13 Clavicles Rotation 13

14 Angulation blurry Motion 14

15 Case 48 yo woman p/w Right sided chest pain, non productive mild cough No medical history PE: HR 105 otherwise normal vitals, slightly drawn general appearance, reproducible ACW pain, lungs clear DDx What do we need to ask about to complete our history? RISK FACTORS We need to convince ourselves.. What do we order? 15

16 Chest Pain/Dyspnea CHEST Risk stratification What are you looking for? What do you NOT want to see? What do you expect to find? Are you satisfied? 16

17 Cardiac RISK FACTORS Age DM, HTN, HLD Smoking Cocaine FH sudden early cardiac death Obesity/sedentary Past history Prior testing? Pulmonary Risk Factors Prolonged immobilization Recent surgery Prior DVT/PE Pregnancy Pelvic/LE trauma OCPs with smoking Cancer FH or PMHx of hypercoagulability 17

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28 30 yo s/p stab wound to L chest initially talking and vitals normal. After 20 mins, becomes altered, sats drop and blood pressure drops 11

29 Case 50 yo man p/w hemoptysis 12

30 Man smoker, with hemoptysis Man w hemoptysis is from Haiti 13

31 Man w hemoptysis and weight loss and back pain 14

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41 Misdiagnosis errors 1. Normal Anatomy 2. Normal Anatomical Variants 3. Pattern Recognition Failure 4. Referral Failure 5. Associated Pathology 6. Inadequate Number of Projections 7. Radiography Failure 8. Photographic vs Clinical Radiography 9. Inclusion Failure 10. Peripherally Positioned Pathology 11. Unexpected/incidental findings 12. Satisfaction Syndrome 13. The extremely subtle and the extremely obvious 14. Soft Tissue signs and False Positives 15. The 'trivial' injury in multitrauma 16. Artifacts 17. A "Fair Miss 24

42 KUB/Abdomen Indications Very few any more Obstruction? Constipation? Obstipation? Organ perforation Dilated loops of bowel Small vs. large 25

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47 BONES Indications for x ray Know which joints have rules associated Knee, foot, ankle Therapeutic radiation Subtleties for each not to miss OP VS NON OP Must know for each fracture Principles Examine/order joints above and below injury Especially ankle tib/fib and/or foot Hip/knee referred pain Always check neuro vascular status DISTAL to injury Start with places that do not hurt. Examine normal side as well first Types of injuries 1

48 Types of fractures Avulsion Comminuted Angulated Displaced Open = Compound Compression Greenstick = incomplete Intraarticular Spiral Pathological Stellate Subluxation Shoulder Examine on all seizure patients Elderly after unwitnessed fall Motorcycle accidents Clavicular fx Humeral head fractures 95% non op. Sling. Scapular fracture/first rib fx High velocity, will have other severe injuries 2

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51 Elbow Occult fractures common Fat pad signs = radial head fracture No rules tender, decreased ROM, swelling, mechanism 5

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53 Wrist/Hand Scaphoid fracture is occult Snuff box tenderness Splint in thumb spika Distal radius/ulnar styloid Dinner fork deformity FOOH 7

54 Basic Management Us (EM) Based Upon: Splint Reduce and Splint Them (Ortho) Reduce and Cast CRPP ORIF Location Intra articular Extra articular Angulation Shortening Displacement Severity Comminution orthobullets.com 8

55 Phalangeal Fracture Proximal Phalanx Fracture Middle Phalanx Fracture Distal Phalanx Fracture (Tuft s Fracture) Phalangeal Fracture Buddy Tape/Splint Call Ortho Extra articular Non displaced Minimal angulation (<10 ) Minimal shortening (<2mm) Intra articular Significant nail bed injury Significantly displaced Irreducible Spare PIP 9

56 Metacarpal Fractures Shaft Head Neck (Boxer s fracture = 4 th /5 th ) Metacarpal Fractures: Treatment Reduce and Splint Call Ortho Stable Non Displaced Minimal Angulation Minimal Shortening MCP Flexion PIP spared Significantly Displaced Shortening > 5mm Intraarticular Fracture (head/base) Multiple Shaft Fractures Significant Angulation/Rotation 10

57 Base of 1 st Metacarpal Fracture Bennett Fracture Intraarticular Rolando Fracture Comminuted Intraarticular Bennett & Rolando: Treatment Thumb Spica Call Ortho Non Displaced Reducible Extraarticular (<30 angulation) Rolando fracture Irreducible Bennett fracture Large fragment Displaced 11

58 Importance? Scaphoid Fracture Most Common Risk for Non Union & AVN Scaphoid Fracture: Treatment Thumb Spica Stable Non Displaced Distal Pole Fracture High Suspicion for Fracture Call Ortho Displaced (>1mm) Proximal Pole Fracture Comminuted Angulation (humpback deformity) 20 Wrist Extension Hold Ace Bandage 12

59 Distal Radius Fracture (extraarticular) Dorsal Angulation (Colles) Volar Angulation (Smith s) Distal Radius Fracture: Treatment Reduce and Sugar Tong Extra articular Non displaced Reducible with < 5 angulation Minimal shortening (<5mm) Call Ortho Severely displaced Irreducible with >5 angulation Significant shortening (>5mm) Comminuted Intra articular 13

60 Normal Lunate Dislocation Volar dislocation of Lunate Perilunate Dislocation Summary Assess the need for emergent reduction Get appropriate films Keep it simple Call ortho when appropriate Go to first Arrange follow up 14

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62 Elderly with falls Examine knee always 2 views 95% OPERATIVE What do you NOT see Avascular necrosis DJD HIP Normal 16

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66 Knee Tough Good exam Lift heel off bed patelar tendon rupture Occult fractures/tendon injuries Tibial plateau fractures keep high suspicion Effusions Patelar dislocations xxxx Ottowa knee rules Age 55 years or older Tenderness at head of FIBULA Isolated tenderness of PATELLA Inability to flex to 90 Inability to bear weight both immediately and in the emergency department (4 steps) 20

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70 Tib/Fib Hard to break tibia, usually obvious/open Fibular fx can be occult always check proximal fibula especially with ankle fractures 24

71 Ankle/Foot Ottowa ankle/foot rules Malleolar fractures Bi mall, Tri mall Fibular fractures Most often non op Posterior splint/crutches/follow up Tibial fractures Check MORTIS Always operative! Normal anatomy Rules Ottowa ankle rules: Tenderness to medial or lateral malleolus Unable to bear weight immediately and in ED Ottowa foot rules: Tenderness at base of 5 th metatarsal Tenderness at navicular medial midfoot 25

72 Foot operative fractures Lisfranc Jones 1 st metatarsal Other metatarsals with severe displacement 26

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