Medical Student Clinical Pearl – PoCUS and Clavicle Fractures

Using PoCUS to diagnose clavicular fractures

Medical Student Pearl – May 2018

Danielle Rioux – Med III Class of 2019, Dalhousie Medicine New Brunswick 

Reviewed by Dr. Mandy Peach and Dr. David Lewis

Case: A 70 year-old man presented to the emergency department with pain in his left shoulder and clavicular region following a skiing accident. He slipped and fell on his left lateral shoulder while he was on skis at the ski hill. He has visible swelling in his left shoulder and clavicular region, and was not able to move his left arm.

On exam: The patient was in no sign of distress. He was standing and holding his left arm adducted close to his body, supporting his left arm with his right hand. There was swelling and ecchymosis in the left clavicle, mid-shaft region, with focal tenderness. On palpation, there was crepitation, tenderness, swelling, and warmth in this region. He was unable to move his left shoulder due to pain. His neurovascular exam on his left arm was normal. Auscultation of his lungs revealed normal air-entry, bilaterally and no adventitious sounds.

Point of Care Ultrasound (PoCUS): We used a linear, high-frequency transducer and placed it in the longitudinal plane on the normal right clavicle (see Image 1.), and the fractured left clavicle (see Image 2.). Image 3 shows the fractured clavicle in the transverse plane.

 

Image 1. PoCUS of normal right clavicle along the long axis of the clavicle (arrows depict the hyperechoic superficial cortex with deep acoustic shadowing).

 

 

Clip 1. PoCUS of normal right clavicle along the short axis of the clavicle. The transducer is moving from the lateral to medial, note the visible hyperechoic curved superficial cortex and the subclavian vessels at the end of the clip. 

 

Image 2. PoCUS of normal right clavicle along the short axis of the clavicle (arrows depict the hyperechoic superficial cortex with deep acoustic shadowing).

 

 

Image 3. PoCUS of a fracture in the left clavicle along the long axis of the clavicle

 

 

Clip 2. PoCUS of a fracture of the left clavicle, viewed in the long axis of the clavicle. Compare this view with image 1.

 

 

 

Clip 3. PoCUS of a fracture in the left clavicle viewed in the short axis of the clavicle. Compare this view with Clip 1. Note the fracture through the visible cortex and the displacement that becomes apparent halfway through the clip.

 

Radiographic findings: Radiographic findings of the left clavicle reveal a mid-shaft spiral clavicular fracture.  (Image 4).

Image 4. Radiographic image of fractured left clavicle.

 

Take home point: Research has shown that Ultrasonography is a sensitive diagnostic tool in the evaluation of fractures (Chapman & Black, 2003; Eckert et al., 2014; Chen et al., 2016).

This case provides an example of how PoCUS can be used to diagnose clavicle fractures in the emergency department. In a rural or office setting where radiography is not always available, PoCUS can be used to triage patients efficiently into groups of those with a fracture and those with a low likelihood of a fracture. This would enable more efficient medical referrals while improving cost-effectiveness and patient care.

 

References:

Chapman, D. & Black, K. 2003. Diagnostic musculoskeletal ultrasound for emergency physicians. Ultrasound, 25(10):60

Eckert, K., Janssen, N., Ackermann, O., Schweiger, B., Radeloff, E. & Liedgens, P. 2014 Ultrasound diagnosis of supracondylar fractures in children. Eur J Trauma Emerg Surg., 40:159–168

Chen, K.C., Chor-Ming, A., Chong, C.F. & Wang, T.L. 2016. An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department, Journal of Intensive Care, 4:55

 

This post was copyedited by Dr. Mandy Peach

 

 

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Pre-hospital Airway Management – the bottom line

Study review of recent Airway World Webinar.

Reviewed by David Lewis and Jay Mekwan

The study: Retrospective Data Review conducted in Australia investigating rates of successful RSI by intensive care paramedics.

Rationale: Controversial whether RSI should be completed pre-hospital as unsuccessful attempts can result in patient complications.

Results: First pass success rate of 89.4% with low rates of complications – hypoxia (1.3%) and hypotension (5.2%).

Bottom line:  Appropriately trained air transport paramedics can perform RSI pre-hospital with high levels of success.

 

The study: Retrospective review of a global database tracking critical care transport program. Looked at first pass success attempts at tracheal intubation in the field

Rationale: Critical care transport teams are the first point of critical care contact for acutely unwell patients. Tracheal intubation can be a lifesaving intervention performed while transporting to a tertiary care center.

Results: First attempt intubation success was higher in adult focused critical care transport paramedics, regardless of the age of the patient (>86%).

Bottom Line: Experience may be a significant factor for intubation success. Experienced intubators have better success rates in all patient age groups.

 

The study: Retrospective chart review of air medical patient records where cricothyrotomy was performed to assess frequency, success and technique.

Rationale: When all other airway maneuvers fail, cricothyrotomy is a potentially lifesaving skill.

The results: Performance of cricothyrotomy is rare (<1% of over 22,000 patients), but when performed had 100% success rate.

Bottom Line: Although a rarely performed skill, Helicopter Emergency Medicine Service providers can successfully perform cricothyrotomy when needed.

 

The study: Multicenter randomized clinical trial comparing outcomes in patients who were either intubated or bagged following out of hospital cardiorespiratory arrest.

Rationale: Bag mask ventilation is an easier clinical technique to perform during CPR and previously reported as superior than intubation in terms of survival. Neurological outcomes at 28 days post arrest had not been reported.

Results: No difference in rates of survival or neurological at 28 days between bagged or intubated patients. Bag mask ventilation was associated with higher regurgitation rates and, in general, were more difficult airways to manage.

Bottom line: We don’t know if bag mask ventilation or intubation is superior. More research needed.

This post was copyedited by Mandy Peach

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Congratulations to Dr. Kavish Chandra!

Congratulations to Dr. Kavish Chandra – recipient of the Iype/Wilfred Resident Award!

Dr. Chandra, a PGY3 in the Integrated Family Medicine/Emergency Medicine program, was one of 3 recipients of the prestigious Iype/Wilfred award. This is awarded annually by the New Brunswick Medical Society to residents who have demonstrated outstanding achievements during their residency training in New Brunswick. Recipients are recognized as being leaders in research and professionalism, and who do so while showing compassion and caring towards patients and colleagues.

This award will be presented to Dr. Chandra at the Celebration of Medicine ceremony hosted by the New Brunswick Medical Society on May 26, 2018.

Congratulations, Dr. Chandra!

Far right: Dr. Chandra in a simulation training session

 

This post was copy edited by Mandy Peach

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