Lower Extremity Deep Venous US Imaging – Illustrations

lower extremity us illustrations

Ultrasound evaluation for deep venous thrombosis (DVT) is one of the 11 core ultrasound applications for emergency physicians as listed in the 2008 American College of Emergency Physicians guidelines (1). Because ultrasound applications started to be implemented into medical school curriculum in many countries, learning basic ultrasound applications as early as possible will benefit medical students and junior residents. In this post, I will share lower extremity venous ultrasound illustrations with you. 

Indications

The clinical indications for performing a lower venous ultrasound examination is the suspicion of a lower extremity DVT in a swollen or discoloured leg. 

Transducer

Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.

lower extremity venous ultrasound - linear transducer

Remember Risk Factors of DVT

  • Age > 60
  • Cancer
  • Central venous catheter/insertion
  • Genetic causes of hypercoagulopaty
  • History of DVT
  • Immobilization
  • Obesity
  • Pregnancy
  • Smoking
  • Trauma or recent surgery
  • Use of birth control pills or hormone replacement therapy

Wells Score for Deep Vein Thrombosis

CriteriaScore
Active cancer(treatment ongoing or within previous 6 months or palliative treatment)
1
Paralysis, paresis, or recent plaster immobilization or of the lower extremities1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia1
Localized tenderness along the distribution of the deep venous system1
Entire leg swollen1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity)1
Pitting edema confined to the symptomatic leg1
Non varicose collateral superficial veins1
Previously documented DVT1
Alternative diagnosis at least as likely as DVT1
DVT evaluation algorithm
Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.
sectional anatomy of lower extremity veins

Normal DVT Ultrasound Findings

normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings

Reference and Further Reading

  1. American College of Emergency Physicians. Emergency ultrasound guidelines 2008. http://www.acep.org/WorkArea/DownloadAsset.aspx?ID=32878. February 2012.

Note: Visual drawings are inspired by the Point-of-Care ULTRASOUND Book.

Cite this article as: Murat Yazici, Turkey, "Lower Extremity Deep Venous US Imaging – Illustrations," in International Emergency Medicine Education Project, February 14, 2020, https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/, date accessed: April 3, 2020

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A simple cellulitis of the foot?

a simple cellulitis of the foot?

Case Introduction

A 47 year old woman comes to a community ED complaining of pain and redness in her right foot developing quickly over two days. She denies any trauma and otherwise feels well. She is not sure, but may have had a “sore” near her toes that has already healed. Patient has diabetes but is normoglycemic. She has no prior history of cellulitis, joint infections or gout. There is no history of immunocompromise, including steroids, or any IV drug use. All vitals are within normal limits and review of systems is negative for fever, chills, respiratory or gastrointestinal symptoms.

On exam, there is generalized edema, erythema and tenderness, but no tenderness out of proportion, and no open sores or ulcerations. A sub-acute appearing callus is apparent on the plantar surface opposite fifth and fourth distal metatarsals. The ankle joint is tender but less so than the foot, and ranging it does not elicit more pain than at baseline. Distal sensation, pulses and toe motion are intact, though capillary refill is slightly delayed.

cellulitis - foot
cellulitis - foot 2

Initial Questions

  • What would be your plan?  And when and how would you present this case to an attending?
  • Are labs indicated, which ones, and what are they expected to show?  Will that change your plan?
  • Any imaging? Your choices range from nothing, to bedside US to look for an abscess, to XR, CT scan or even an MRI, if available.
  • Is she a candidate for oral antibiotics and discharge? If so, what sort of follow up does she need?
  • Is there any benefit of IV antibiotics if the patient is going to go home?
  • What is the worst case scenario here that may not be apparent? Is there any threat to life, limb or both?

Basic labs obtained are unremarkable and patient is receiving IV broad spectrum antibiotics, including MRSA coverage. Plain films are obtained, and there is some concern for small air pockets in the soft tissues.

cellulitis - xray 2
cellulitis - xray

A phone consultation with podiatry is obtained. A decision is made to take the patient to the OR on the same evening. No further imaging or diagnostic studies are advised.

Additional Questions

  • What if there is no podiatry, and your general or orthopedic surgeon does not handle foot cases? What if there is no surgical coverage at all?
  • Would there be a role for a limited ED I&D or needle aspiration in this case?
  • Would you transfer this case? How do you justify it, if all the labs and vitals are normal?

After the callus is taken off in the OR, large amount of frank pus is obtained that tracks all the way to the third metatarsal. A debridement is performed, and long term antibiotics with close follow up are needed. Overall impression was that while no necrotizing infection was found, any further delay would have risked a trans-metatarsal amputation (at the least).

Key Points

While we do not have room for a lengthy discussion on differentiating plain cellulitis from “other”, it is worthwhile to note several things:

  • Do not get locked in onto cellulitis as the diagnosis. Abscesses, necrotizing infections and septic joints need to be considered and ruled out at all times.
  • Susceptible populations such as diabetics and IV drug users are easy.  But the rapidity of symptom development is just as important in any population.
  • Beware even chronic appearing calluses as masking places for pus and as barriers to its natural drainage.
  • More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
  • More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
  • To I&D or not to I&D is often the question. Good news is that more often than not I&D is the right answer. There is a reason you have already thought of it. You are in the ED - the last line of defense for many patients. Pus needs to come out. The surgeons are not the only guys with knives. Don’t let yourself or anyone talk you out of it. For the tremulous patients (and providers), there is ketamine.
Cite this article as: Anthony Rodigin, USA, "A simple cellulitis of the foot?," in International Emergency Medicine Education Project, February 7, 2020, https://iem-student.org/2020/02/07/educational-case-a-simple-cellulitis-of-the-foot/, date accessed: April 3, 2020

Further Reading

Salter-Harris Fractures

salter harris

Case Presentation

You are a medical student doing your first clinical shift as part of your Emergency Medicine rotation. A 9-year-old boy is brought in by his father after an injury to his left hand approximately 1 hour back. As explained by the father, the child was playing at home with his elder brother when his left index finger became caught in between a door that had quickly slammed shut. Following the injury, the child was reported to be crying due to severe pain, but had no lacerations or other associated injuries. He was rushed to the hospital and presented in the ED as an anxious, weeping boy who held out his left index finger and pointed to the tip as the region of maximal pain. Mild swelling was noted at the distal interphalangeal joint as well as at the tip of the affected finger. After appropriate analgesia was initiated, the child was sent to the Radiology department for X-ray imaging. The images obtained by the department are shown below in Figures 1.1 and 1.2.

Figure 1.1
Figure 1.1
Figure 1.2
Figure 1.2

Findings

Due to the lack of ideal positioning and suboptimal cooperation from the child and his parent, the radiology technician reports back to you stating that the best images they could obtain were the ones displayed above. Although unclear, you can confidently identify a small break in the bone at the base of the distal phalanx. You mention to the father that you see a fracture on the X-ray and report back to your Attending Physician. 

The Attending Physician decides to take a break from his morning coffee and utters the dreaded question: “What kind of fracture is this?” You try to recall a lecture you had about Salter-Harris fractures but cannot recall the classification of these fractures. As if on cue, the father of the patient finds you shuffling your weight in front of the Attending Physician and asks: “You said he has a fracture, will he have to get surgery for his finger?”

“What kind of fracture is this?”

Salter-Harris Fractures

Salter-Harris Fractures refer to fractures that involve the growth plate (physis). Therefore, these fractures are applicable specifically to the pediatric population, occurring most often during periods of rapid growth (growth spurts) when the growth plate is at its weakest, close to age ranges where children tend to participate in high-risk activities (11-12 in girls and 12-14 in boys) [1].

Originally described in 1963 by Dr Robert Salter and Dr Robert Harris [2], the now infamous Salter-Harris fractures are classified by the region of bone that is affected. Figure 2 displays the gross anatomy of a normal distal phalanx similar to the picture we examined in the X-ray, labelled to reflect the different areas of the bone relative to each other. The types of fractures that can occur are outlined below.

SALTER HARRIS ANATOMY
Figure 2
  • Type I Salter-Harris Fractures (Slipped)

    Type I fractures occur when a longitudinal force is applied across the physis, resulting in a displacement (“slip”) of the epiphysis from the metaphysis. Though relatively infrequent (5%), suspicion of this fracture is raised when the epiphysis is seen to either be displaced to the side of its original position relative to the metaphysis or when the gap between the two segments is widened.

Salter-Harris Type I
Salter-Harris Type I
  • Type II Salter-Harris Fractures (Above)

    Type II fractures are the most common (75%) of the Salter-Harris fractures. As with our patient above, this fracture only involves structures “Above” the epiphysis (Metaphysis + Physis/growth plate) with virtually no fracture or displacement of the epiphysis itself. Fortunately, type I and most type II fractures can be managed conservatively with cast immobilization and splinting.

Salter-Harris Type II
Salter-Harris Type II
  • Type III Salter-Harris Fractures (Lower)

    Type III fractures involve both the physis and the epiphysis. Although relatively uncommon (10%), the involvement of the epiphysis and consequent disruption of the growth plate makes this an intra-articular fracture that usually requires surgical fixation.

Salter-Harris Type III
Salter-Harris Type III
  • Type IV Salter-Harris Fractures (Through)

    Continuing the trend of worse outcomes with higher classification types, Type IV fractures involve all three layers (metaphysis, physis and epiphysis) and thus harbor more adverse outcomes and risks, with management primarily consisting of operative internal fixation. Similar to Type III fractures, this is an intra-articular fracture and also occurs at a similar rate of 10%.

Salter-Harris Type IV
Salter-Harris Type IV
  • Type V Salter-Harris Fractures (Rammed/Crushed)

    The rarest of all the Salter-Harris fractures, type V fractures occur due to high impact compression of the growth plate. Potential disruption of the germinal matrix and compromised vascular supply to the growth plate can lead to growth arrest.

Salter-Harris Type V
Salter-Harris Type V

A convenient method to recall the Salter-Harris classifications is outlined below using the mnemonic “SALTR”

Salter-Harris Classification
Salter-Harris Classification

Case Resolution

You ascertain the patient’s fracture to be a type II Salter-Harris fracture, justifying your answer to the Attending Physician by pointing out that the affected region in the X-ray is limited to the metaphysis and physis with no epiphyseal involvement. Recognizing the potential for parental misconceptions surrounding the diagnosis of fractures in pediatric patients [3], you approach the father and explain that, though there is a fracture present, there is likely no need for any surgical intervention. You advise that the left index finger will be immobilized using a splint and further elaborate on the unlikelihood of this injury to manifest any long-term developmental or growth arrest in the affected region.

References and Further Reading

  1. Levine RH, Foris LA, Nezwek TA, et al. Salter Harris Fractures. [Updated 2019 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  2. Salter, Robert B.; Harris, W. Robert: Injuries Involving the Epiphyseal Plate, The Journal of Bone and Joint Surgery (JBJS): April 1963 – Volume 45 – Issue 3 – p 587-622
  3. Sofu H, Gursu S, Kockara N, Issin A, Oner A, Camurcu Y. Pediatric fractures through the eyes of parents: an observational study. Medicine (Baltimore). 2015;94(2):e407. doi:10.1097/MD.0000000000000407
Cite this article as: Mohammad Anzal Rehman, UAE, "Salter-Harris Fractures," in International Emergency Medicine Education Project, December 23, 2019, https://iem-student.org/2019/12/23/salter-harris-fractures/, date accessed: April 3, 2020

I woke up like that! – Bilateral Shoulder Pain

bilateral shoulder pain

Case Presentation

A 35-year-old male presented to fast track complaining of bilateral severe shoulder pain for one-day duration. He reports waking up like that, and not being able to move his shoulders much due to the pain.

He denied any recent falls, injuries, or direct trauma to his shoulders. He also denied any fever, rashes, skin changes, headaches, numbness or weakness. No further findings found upon review of systems. Past medical history revealed a history of epilepsy. Otherwise, he’s not on any medications and denies any known allergies.

Physical examination showed slim male, with flattened anterior shoulders and normal inspection of the skin overlying his shoulders. He had internally rotated upper extremities, flexed elbows, and arms held in adduction. Upon attempts on any passive or active test of the range of motion, he experienced reluctance and pain on external rotation or abduction of his shoulders. Bilateral Shoulder X-rays were obtained.

shoulder dislocation and fracture 1
shoulder dislocation and fracture 2

This patient had bilateral posterior shoulder dislocation, with associated fractures.

    • Posterior shoulder dislocations make up 2-4% of shoulder dislocations.
    • May go undiagnosed and often missed on physical exam and imaging
    • Epileptic seizures or electrical shocks, sports injuries are the most common causes.
    • Subtle signs on AP X-Ray include:
        • Light Bulb Sign: Fixed internal rotation of the humeral head, makes the greater tuberosity anterior, giving a symmetrical appearance of the humeral head, that looks like a light bulb.
        • Empty Glenoid Sign: Humeral Head and Glenoid fossa widened articular space
        • Trough Sign: Vertical Line on AP, can indicate compression fracture of the humeral head medially.
    • In suspected Posterior Shoulder Dislocations, you should always get multiple views, including Anterior-Posterior (AP), scapular (Y), and Axillary Views.
    • Rounded posterior shoulder.
    • Prominent coracoid and acromion.
    • Palpable posterior humeral head.
    • Flattened anterior shoulder contour.
    • Neurovascular injuries
    • Rotator cuff tears
    • Osteonecrosis of the humeral head
    • Recurrent posterior shoulder instability or re-dislocation
    • Joint stiffness and post-traumatic osteoarthritis
    • You need to evaluate each case separately. The cases like this patient, with associated fractures, can complicate your management, and hence consulting orthopedic services would be advised, as surgical interventions should be evaluated.
    • If closed reduction fails, usually open reduction is pondered by subspecialty, especially in cases with extensive damage to the humeral head.
    • In cases with no associated fractures, the approach is the reduction of the dislocation. Most of them would require procedural sedation and analgesia.
    • Consider discussing options of procedural sedation and analgesia, with or without intraarticular blocks with your attending, for better and successful procedures, and minimal pain for your patient. The most convenient procedure options should also be discussed with patients, and consent should be taken. 
    • Patients would require pre and post-reduction neurovascular examination and X-rays.
    • Make sure your patient is examined again after the procedure, assessing the stability of the joint for regained full range of motion. 
    • Shoulder immobilization and follow up care plans with orthopedics services should be arranged.
    • Don’t forget, patients with known epilepsy, non-adherence or uncontrolled seizures have to be evaluated as well, and referred to appropriate neurology evaluation.

Case Reflections

  • Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations.
  • Bilateral fracture-dislocation is even rarer, with a few cases reported in the literature.
  • In the rare case of an asymmetrical bilateral dislocation, attention may be distracted to the more evident lesion, which is the anterior dislocation. This may lead to delayed diagnosis, especially in an unconscious patient in a post-ictal state.
  • In the present case, open reduction and internal fixation was performed.

References and Further Reading

  1. Roberts & Hedges Clinical Procedures in Emergency Medicine (6th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 49
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed) 2011. New York. McGraw Hill Companies Inc. – Chapter 268
  3. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 53
  4. Wikem – Posterior Shoulder dislocation: https://www.wikem.org/wiki/Posterior_shoulder_dislocation
  5. Canadiem – Posterior Shoulder Dislocation: Radiographic Evidence : https://canadiem.org/posterior-shoulder-dislocation-radiographic-evidence/ 
  6. Meena S, Saini P, Singh V, Kumar R, Trikha V. Bilateral anterior shoulder dislocation. J Nat Sci Biol Med. 2013;4(2):499–501. doi:10.4103/0976-9668.117003S – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783813/
  7. Sharma A, Jindal S, Narula MS, Garg S, Sethi A. Bilateral Asymmetrical Fracture Dislocation of Shoulder with Rare Combination of Injuries after Epileptic Seizure: A Case Report. Malays Orthop J. 2017;11(1):74–76. doi:10.5704/MOJ.1703.011 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393121/

Acknowledgement

Credit and acknowledgment for Dr. Eelaf Elhassan for sharing the case.

Cite this article as: Shaza Karrar, UAE, "I woke up like that! – Bilateral Shoulder Pain," in International Emergency Medicine Education Project, December 13, 2019, https://iem-student.org/2019/12/13/bilateral-shoulder-pain/, date accessed: April 3, 2020

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Cellulitis – Clinical Image and Ultrasound

cellulitis

Case Presentation

A 45-years-old male with a week history of right leg swelling and redness presented to the ED. He has type II DM and hypertension. He denies fever; however, complaints about burning pain over the skin. Vitals were 156/98 mmHg blood pressure, 98 beats per minute heart rate, 16 respiration per minute, 36.7 degrees Celsius temperature and 98% oxygen saturation in room air. Physical exam revealed erythema over the right medial lower leg and calf area (images). Minimally painful with palpation. The area was hot compared to the left leg. Other examination findings were unremarkable.

Cellulitis 2

Cellulitis 1

Patients with red, swollen, painful leg may have very severe problems such as necrotizing fasciitis (infection involving muscular fascia) or infections involving muscles with or without gangrene. The patients having these infections are generally ill-looking, severely painful, and may have subcutaneous crepitations. Therefore, we should be aware of these red flags. This patient has no sign of crepitations, systemic illness, or severe pain.

Lipodermatosclerosis is chronic erythema. Patients show exacerbations because of vascular insufficiency (venous). It can be bilateral or unilateral. One of the discriminative findings from cellulitis is temperature over the lesion. Lipodermatosclerosis is not hot. In the case, the palpation showed warm skin compared to the left side.

Erysipelas is superficial and its’ borders are very sharp. The lesion is fluffy compared to the skin around the lesion. In the case, some areas of the skin were found a little bit raised compared to surrounding structures. However, its’ borders were not well-demarcated.

Other differentials are burns, contact dermatitis, urticaria, etc.

Bedside ultrasound imaging can help to identify cellulitis, abscess, foreign body, fracture, etc. Cobblestone finding is a typical finding for cellulitis.

Bedside ultrasound imaging was performed with Butterfly iQ with soft tissue settings. Cobblestone finding was found in the erythematous areas. This is a nonspecific finding and can be seen many different soft tissue infections. There were no gas/air artifacts (necrotizing fasciitis) or obvious abscess formation. However, there was a minimal fluid accumulation, which creates a suspicion of an abscess. In the case, there was no air artifact. However, x-rays can also help to show air accumulation in soft tissues.

An Example for Necrotizing Fasciitis

The ultrasound investigation in this video shows the air (white) artifacts in the soft tissue.

X-ray Image Showing Subcutaneous Air in Necrotizing Fasciitis

Case courtesy of Dr Matt Skalski, Radiopaedia.org. From the case rID: 25026

For mild uncomplicated patients – dicloxacillin, amoxicillin, and cephalexin are common choices.

If the patient has a penicillin allergy – clindamycin or a macrolide (clarithromycin or azithromycin) can be used.

Fluoroquinolones should be reserved for gram-negative organisms’ sensitivity defined by culture results because of their additional toxicity risks.

For more antibiotic options and explanations, please visit – here

The patients with co-morbidities compromising immune response, periorbital or perianal locations, unable to tolerate oral medication, deep infections should be admitted.

References and Further Reading

  • Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR Am J Roentgenol. 1996 Jan;166(1):149-52. PubMed PMID: 8571865.
  • Shyy W, Knight RS, Goldstein R, Isaacs ED, Teismann NA. Sonographic Findings in Necrotizing Fasciitis: Two Ends of the Spectrum. J Ultrasound Med. 2016 Oct;35(10):2273-7. doi: 10.7863/ultra.15.12068. Epub 2016 Aug 31. PubMed PMID: 27582527.
Cite this article as: Arif Alper Cevik, "Cellulitis – Clinical Image and Ultrasound," in International Emergency Medicine Education Project, December 2, 2019, https://iem-student.org/2019/12/02/cellulitis-clinical-image-and-ultrasound/, date accessed: April 3, 2020

Hepatobiliary US Imaging – Illustrations

hepatobiliary ultrasound

Anatomy Of The Hepatobiliary System

Anatomy of the hepatobiliary system

Indications

Indications for clinicians to perform point-of-care hepatobiliary ultrasound include the evaluation of; abdominal pain, jaundice, sepsis and ascites.

Transducer

The most commonly used positions include; left lateral decubitus and supine position. A low-to medium-frequency (2–5 MHz) curvilinear ultrasound transducer will suffice for most ultrasound examinations of the gallbladder.

curvilinear transducer

Patient positioning

Patient positioning plays a vital role in the hepatobiliary ultrasound examination. Transducer position according to gallbladder; longitudinal and transverse.

Focus Points on Hepatobilary Ultrasound

focus points hepatobilary ultrasound

Patient Position and Transducer Position

Patient Position and Transducer Position​
Patient Position and Transducer Position​

Normal Hepatobiliary Ultrasound Findings

Normal Hepatobiliary Ultrasound Findings​

Pathological Hepatobiliary Ultrasound Findings

Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Cite this article as: Murat Yazici, Turkey, "Hepatobiliary US Imaging – Illustrations," in International Emergency Medicine Education Project, November 27, 2019, https://iem-student.org/2019/11/27/hepatobiliary-us-imaging-illustrations/, date accessed: April 3, 2020

Massive Pneumothorax Without A Tension

massive pneumothorax

Case Presentation

A 24-years-old male with shortness of breath and chest pain presented to the emergency department. He was alert and oriented. Vitals were as follows; BP: 127/65 mmHg, HR: 101 beats per min, RR: 24 breaths per min, T: 37-degree celsius, SatO2: 94%. Physical examination revealed that normal breathing sounds on the left side, but decreased breath sounds on the right side of the chest. No JVD noted. Other examination findings were unremarkable.

Shortness of breath and chest pain started suddenly while he was playing soccer about 30 minutes ago. Since then, shortness of breath and chest pain increased. He has no known medical disease, allergy.

Bedside ultrasound revealed pneumothorax on the right.

Bedside Ultrasound Examination

Above video shows left side B mode ultrasound examination. Investigation was done in lung settings by using Butterfly iQ portable ultrasound. Lung sliding and comet tail artefacts are seen on examination which is normal findings.

Above video shows right side B mode and M-mode ultrasound examination. There is no lung sliding or comet tail artefacts in B mode, and M-mode revealed “barcode sign” which is seen in pneumothorax.

Pneumothorax - US - Lung - M-mode

Image shows “barcode sign” in M-mode examination. 

Bedside Portable Chest X-ray

spontaneous pneumothorax 1 - 18yo male

Bedside portable anteroposterior chest x-ray shows right sided large pneumothorax.

Cite this article as: Arif Alper Cevik, "Massive Pneumothorax Without A Tension," in International Emergency Medicine Education Project, November 25, 2019, https://iem-student.org/2019/11/25/massive-pneumothorax-without-a-tension/, date accessed: April 3, 2020

Torus Fracture – Diagnosed with ultrasound

torus fracture

Case Presentation

A 9-years old male patient brought to the ED by his parents because of the right forearm pain. The patient is alert, oriented, and moderately in distress. He described that he stepped on the ball and fell while playing soccer with his friends. He denies any other injury, loss of consciousness, etc.

Physical Exam

Torus Fracture - right arm 2

The patient complaints right forearm pain, especially distal 1/4 of the radius. There was no deformity or swelling recognized on inspection. 

Torus Fracture - right arm 1

The patient refuses any movement on the right arm because of pain during the movement, especially in rotational movements. He prefers to stay in the rest position, as shown in the picture.

There was no visible deformity and swelling in the inspection. However, the patient described palpation tenderness over the forearm, especially point tenderness over the distal 1/4 – 1/5 of the radius. The patient also described minimal pain on elbow and wrist movements. The neurovascular examination was unremarkable. There are no other findings regarding trauma. Patient parents deny any disease, medication, operation, etc. He has received 250 mg paracetamol in the school after consultation with the family. However, he still shows distress because of pain.

After the physical exam, 200 ibuprofen was given. X-ray is planned, and musculoskeletal ultrasound was applied while he waits for an X-ray.

We used Butterfly iQ to investigate the radius by using musculoskeletal settings. The ultrasound showed periosteal discontinuity with a 2-3 mm step-off sign at the distal radius. 

Diagnosing fractures with ultrasound

Ultrasound showed high pooled sensitivity (91%) and specificity (94%) (Schmid et al., 2017). It is a very effective modality, especially in the detection of long bone fractures such as humerus, forearm, tibia, fibula, etc.

In forearm fractures, its’ sensitivity is between 64 and 100%, its’ specificity is between 73-100% (Katzer et al., 2016). Besides, ultrasound provides 25 minutes earlier diagnosis advantage compared to other modalities, namely X-rays. Ultrasound’s effectiveness has elbow, been shown in many articles, its’ best performance is on diaphysis fractures of long bones (Weingberg et al., 2010).

After the detection of Torus (Buckle) fracture by ultrasound, the patient was sent to X-ray in order to investigate elbow, forearm and wrist in more detail. X-rays showed Torus fracture at the distal radius, which the diagnosis aligned with the ultrasound result.​

Torus Fracture - right arm 4

Torus Fracture - right arm 3

AP X-ray showed minor periosteal step-off/bulging on both sides. Lateral X-rays showed periosteal discontinuity with a 2-3 mm step-off on the dorsal side of the radius.

The final diagnosis of the patient was Torus (Buckle) fracture.

A long arm splint was applied in the ED because of his elbow and wrist pain. The patient discharged with pain medication, ice and elevation recommendations. On the 4th day, the patient visited the orthopedic clinic, and his splint changed to short arm splint. He was pain-free on the elbow and wrist.

References

  1. Schmid GL, Lippmann S, Unverzagt S, Hofmann C, Deutsch T, Frese T. The Investigation of Suspected Fracture-a Comparison of Ultrasound With Conventional Imaging. Dtsch Arztebl Int. 2017 Nov 10;114(45):757-764. doi: 10.3238/arztebl.2017.0757. PubMed PMID: 29202925; PubMed Central PMCID: PMC5729224.
  2. Katzer C, Wasem J, Eckert K, Ackermann O, Buchberger B. Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation. Pediatr Emerg Care. 2016 Jun;32(6):401-7. doi: 10.1097/PEC.0000000000000446. Review. PubMed PMID: 26087441.
  3. Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010 Aug;41(8):862-8. doi: 10.1016/j.injury.2010.04.020. Epub 2010 May 13. PubMed PMID: 20466368.
 
Cite this article as: Arif Alper Cevik, "Torus Fracture – Diagnosed with ultrasound," in International Emergency Medicine Education Project, November 6, 2019, https://iem-student.org/2019/11/06/torus-fracture-diagnosed-with-ultrasound/, date accessed: April 3, 2020

Top Images From iEM Archive

Top Images From iEM Archive
17 - epidural + air

Epidural hemorrhage and free air

12.1 - central catheter misplaced

Central venous catheter misplacement

757.3 - Childhood rush - HFM disease

Childhood rush – HFM disease

26.1 - pneumocaccal meningitis 1

Pneumococcal meningitis, MRI

130.1 - SAH - subarachnoid hemorrhage

Subarachnoid hemorrhage

627.3 - Figure 03 - ICH in the right parietotemporal lobe

Intracranial hemorrhage at temporoparietal location

685.2 - electrical injury entry

Electrical injury, entry

449.3 - subacute subdural3

Subdural hemorrhage

336.5 - normal PA chest x-ray HEART BORDERS

Normal heart borders, normal chest x-ray

ELECTRIC SHOCK; Injuries beyond what the eyes see.​

electric shock

Authors: Dr. Nour Saleh and Dr. Kilalo Mjema

Case presentation

A 53-years-old male, sustained burn wounds on both hands 40 minutes prior presentation to the ED

Primary survey

  • Airway: patent and protected.
  • Breathing: bilateral equal air entry
  • Circulation: warm extremities, capillary refill time is 1 second
    • Vitals on presentation
      • BP: 177/114mmHg
      • HR: 115
      • RR: 16
      • SPO2: 96% in room air
      • T: 36.4
  • Disability: alert and oriented, pupils 5mm bilateral equal light reaction, glucose: 7.3mmol
  • Exposure: holding his hands up in pain with some black discoloration

SAMPLE History

  • Sign and symptoms: pain, see pictures
  • Allergy: no known allergies
  • Medications: not on any medication
  • Past medical history: no known comorbid or any significant medical history
    Last meal: he ate about 2.5 hours prior presentation
  • Event: pain on both hands after sustaining burn injury forty minutes prior presentation to the ED while trying to connect two circuits that sparked causing burn wounds on his hands and felt a jolt of electricity.

No history of heartbeat awareness or any loss of consciousness

electrical injury
electrical injury

Interventions and key steps in management

  • Make sure ABCD is checked and there is no critical intervention needed
  • IV access and fluid resuscitation may be considered depending on the case
  • Analgesics: depends on the severity of pain. Fentanyl 50mcg IV stat can be necessary for many patients.
  • Informed consent for procedural sedation for the dressing of the wounds.
  • Sedation: during the dressing of wounds
  • Point-of-care investigations: ECG, Urine dipstick
  • Blood samples for some labs should be taken; Creatinine, CK, Myoglobin, Electrolytes, Calcium, and Troponin
  • Imaging: X-ray if there is a worry for associated fracture
  • Monitor: input of fluids and output of urine to watch for acute kidney injury, compartment syndrome and rhabdomyolysis
  • Do not forget tetanus immunization

Associated injuries

  • Cardiac arrhythmias

    Ventricular fibrillation is the most common. It occurs in 60% of patients with electrical current traveling from one hand to the other.

  • Renal - Rhabdomyolysis

    Massive tissue necrosis may result in acute kidney injury. Labs to check includes; Creatinine, Blood Urea Nitrogen, Total CK, myoglobin.

  • Neurological

    Damage to both central and peripheral nervous systems can occur. The presentation may include weakness or paralysis, respiratory depression, autonomic dysfunction, memory disturbances, loss of consciousness.

  • Skin

    Degree of injury cannot determine the extent of internal damage especially with low voltage injuries. Minor surface burns may co-exist with massive muscle coagulation and necrosis.

  • Musculoskeletal

    Bones have the highest resistance of any body tissues resulting in the greatest amount of heat when exposed to an electrical current. Results in surrounding tissue damage and potentially may lead to periosteal burns, destruction of bone matrix and osteonecrosis.

  • Vascular / Coagulation system

    Due to electrical coagulation of small blood vessels or acute compartment syndrome.

  • Internal organs

    The internal organ injury is not common but when it happens may result serious problems such as bowel perforations leading to polymicrobial infection, sepsis, and death.

Disposition

Admission and discharge decisions of burn patients depend on the patient’s current situation, burn percentage according to body surface area, location of the burn, and complications of burn. Low voltage electrocutions, if they are asymptomatic with normal physical examinations, can be discharged. Discharge precautions regarding burn care and complications should be clearly explained to the patient and relatives.

Further Reading

Cite this article as: Kilalo Mjema, "ELECTRIC SHOCK; Injuries beyond what the eyes see.​," in International Emergency Medicine Education Project, October 2, 2019, https://iem-student.org/2019/10/02/electric-shock-injuries-beyond-what-the-eyes-see-%e2%80%8b/, date accessed: April 3, 2020

Purple Rain: A Rare Spot Diagnosis

Purple rain urine

Case Presentation

A 70-year-old pleasant elderly male was brought in by his son, surprisingly complaining of purple-colored urine. The son got worried once he saw the purple urine bag and rushed his dad to the Emergency Department.

Upon further questioning, he reports a sweet elderly gentleman, known with previous cerebrovascular accidents, dysphasia and neurogenic bladder, that he has a urinary catheter inserted for. He claims that his dad has been having low appetite and passing less stool in the past week. Otherwise, he didn’t notice any other alarming symptoms. Furthermore, he denied noticing any fever, vomiting, behavioral changes indicating any pain, or recent change in his medications or diet. He had no known allergies as well. Upon full review of symptoms, chronic constipation was appreciated, otherwise, it was unremarkable.

Physical Exam

The patient was lying in bed, a bit uncomfortable, with an attached urinary catheter bag. He was afebrile and vitally stable. Proceeding with a focused physical examination, his chest was clear, and abdomen was soft, lax and nontender, furthermore, his skin had no rashes, and limbs were non-edematous. Inspecting the Urine Catheter Collection Bag, it did reveal Purple Urine Sediment.

Purple Urine in the Urinary Catheter Bag
Purple Urine in the Urinary Catheter Bag

Differential Diagnosis and Workup

Thinking of differential diagnoses of discolored urine, a purple urine bag is almost a spot diagnosis in our practice, definitely after ruling out any possible confounders if any.

We reassured the family and explained to them that we would order some blood and urine tests to confirm the diagnosis and start the appropriate treatment plan.

Case Management and Disposition

Laboratory test revealed mild leukocytosis with neutrophilia and mild elevated CRP. Otherwise, his urea, creatinine, liver function tests and electrolytes were reported normal.

Furthermore, a urine dipstick was done in the ED that reported positive for leukocytes, nitrites, and consequently sent to the lab for culture and full analysis which confirmed the diagnosis of a urinary tract infection (UTI).

We informed the son of the workup results, and a diagnosis of a UTI, given his leukocytosis, positive urine dipstick and the presence of a urinary catheter putting him at risk UTI. We reassured him about the urine color and explained the need to start antibiotics to cover the UTI, and changes the urinary catheter, which left us to explain only why was the urine purple unlike usual cases of UTI’s.

Critical Thinking and Take-home Tips

What is PUBS?

  • PUBS stands for Purple Urinary Bag Syndrome, first described in 1978.(1)
  • It is characterized by purple-colored urine collecting in urinary catheterization bags in patients known to prolonged urinary catheters. 
  • It presents asymptomatically and it is associated with urinary tract infections.
  • PUBS presents alarmingly to patients and family members, yet it is a benign phenomenon.

What causes the purplish discoloration of the urine in PUBS?

  • PUBS is associated with alkaline urine with a high bacterial load. 
  • It results due to UTI with certain bacteria producing sulphatases and phosphatases, which lead tryptophan metabolism to produce indigo (blue) and indirubin (red) pigments, a mixture of which becomes purple. (2)
  • Several bacterial species have been reported in association with PUBS including Providencia stuartii, Providencia rettgeri, Klebsiella pneumoniae, Proteus species, Escherichia coli, Enterococcus species, Morganella morganii, and Pseudomonas aeruginosa. (3)

What are the PUBS risk factors?

  • Female gender
  • Bedridden status or immobility
  • Chronic constipation leading to bacterial overgrowth
  • Renal disease
  • Prolonged urinary catheterization

What is PUBS management?

  • The reassurance of patient and family
  • Regular changing of urinary catheter
  • UTI Antibiotics coverage

What other urine colors should we be aware of?

  • Urine discoloration if a fairly common sign and indicates a certain pathology often that would need your attention as a physician.
  • Most urine discoloration is caused by food intakes, medications, dyes, or specific disease pathologies.
  • Red-colored urine is often related to hematuria, caused by multiple pathologies, including kidney stones, urinary tract injury or infection or cancer, amongst others.
  • Pink colored urine is often related to certain medications or dietary intake, i.e. beetroots and berries.
  • Brown or tea-colored urine indicates hepatobiliary disease or obstruction.
  • Green Urine can result due to medications such as Propofol.

What should I do when I encounter a discolored urine finding in my patient?

  • Remember always to have a systematic approach. 
  • Take a full history, including types or changes in medications history, diet changes, past medical history, and a full review of systems.
  • Keep in mind, some patients who are bedridden or elderly, communication and history taking might be limited; hence you will have to do your due diligence in gathering all the information you can get from family members, or available medical charts.
  • Your physical exam is a great asset as well in collecting information that can help you 

References and Further Reading

  1. Khan F, Chaudhry MA, Qureshi N, Cowley B. Purple urine bag syndrome: An Alarming Hue? A Brief Review of the Literature. Int J Nephrol 2011. 2011 419213. [PMC free article] [PubMed] [Google Scholar]
  2. Kalsi DS, Ward J, Lee R, Handa A. Purple Urine Bag Syndrome: A Rare Spot Diagnosis. Dis Markers. 2017;2017:9131872. doi:10.1155/2017/9131872
  3. Dilraj S. Kalsi, Joel Ward, Regent Lee, and Ashok Handa, “Purple Urine Bag Syndrome: A Rare Spot Diagnosis,” Disease Markers, vol. 2017, Article ID 9131872, 6 pages, 2017. https://doi.org/10.1155/2017/9131872.
  4. Al Montasir A, Al Mustaque A. Purple urine bag syndrome. J Family Med Prim Care. 2013;2(1):104–105. doi:10.4103/2249-4863.109970
  5. Traynor B P, Pomeroy E, Niall D. Purple urine bag syndrome: a case report and review of the literature. Oxford Medical Case Reports, Volume 2017, Issue 11, November 2017, omx059, https://doi.org/10.1093/omcr/omx059
  6. Lin CH, Huang HT, Chien CC, Tzeng DS, Lung FW. Purple urine bag syndrome in nursing homes: Ten elderly case reports and a literature review. Clin Interv Aging. 2008;3:729–34. [PMC free article] [PubMed] [Google Scholar]
Cite this article as: Shaza Karrar, UAE, "Purple Rain: A Rare Spot Diagnosis," in International Emergency Medicine Education Project, September 20, 2019, https://iem-student.org/2019/09/20/purple-rain-a-rare-spot-diagnosis/, date accessed: April 3, 2020

Cranial CT Anatomy: A simple image guide for medical students

cranial ct anatomy

Computed tomography (CT) is the most useful brain imaging tool in emergency medical practice. It is also the first imaging modality in patients presenting to the emergency department with headache, stroke and head trauma.

Many cranial lesions can easily be recognized in CT. One of the key points of diagnosing cranial lesions is knowing the anatomical structures. This gives us the advantage to evaluate CT by combining clinical findings with the image.

We created an image series for the most essential eight anatomical structures.

cranial CT slices

Centrum Semiovale

centrum semiovale

Lateral Ventricles

lateral ventricles

3rd Ventricle, Basal Ganglia, Superior Cerebellar Cistern

3rd Ventricle, Basal Ganglia, Superior Cerebellar Cistern​

3rd Ventricle, Basal Ganglia, Quadrigeminal Plate

3rd Ventricle, Basal Ganglia, Quadrigeminal Plate

Midbrain, Interpeduncular Cistern​

interventricular cistern

Suprasellar Cistern, 4th Ventricle

Suprasellar cistern, 4th ventricle

Sella Turcica

sella turcica

Pons, Medullary Junction

pons medullary junction

Further Reading

Bonus Infographic

Cite this article as: Murat Yazici, Turkey, "Cranial CT Anatomy: A simple image guide for medical students," in International Emergency Medicine Education Project, September 4, 2019, https://iem-student.org/2019/09/04/cranial-ct-anatomy-a-simple-image-guide-for-medical-students/, date accessed: April 3, 2020