Tag Archives: ortho

Approach to Foot Radiographs

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Resident Pearl by Dr. Sarah Belbraouet

Diagnostic Radiology PGY2

Dalhousie University

Reviewed by Dr. R Goss

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ SBelraouet An Approach to Foot Radiographs

Foot XRs in the ED

Foot Radiographs are often requested in the emergency department. Indicated in cases of trauma, infection, or pain for instance, it is essential to have an efficient and structured approach to reading these studies.

Using a consistent approach to any radiograph is key to overcoming common pitfalls and blind spots in imaging. This resident clinical pearl will provide a systematic approach that can be molded into personal preferences (1).

1. Adequacy (2)

A standard foot radiograph includes an AP or anteroposterior view (also called DP view or dorsoplantar), a lateral view and an oblique view.

  • AP view: all metatarsal bones should be appropriately visible.
  • Oblique view: taken with a 30-40 degree medial angulation of the foot.
  • Lateral view: includes a projection of the ankle. Here, the base of the 1st, 2nd and 3rd metatarsal should align with the three cuneiforms.

 

 Figure 1: Foot series

 

Figure 2: Foot Anatomy

2. Soft Tissue

Assess for soft tissue swelling and/or effusion; these findings can guide you to an underlying pathology (i.e.: fracture).

3. Bone (1)

Outline the cortex of each bone to assess for fractures.

  • Beware that subtle and frequently missed fractures usually occur at the base of the metatarsal bones.
  • An unattached bone may represent a bone fragment, an avulsion fracture, or an accessory ossicle in which case, could be normal variant anatomy.

4. Cartilage and Joints (2)

Always look out for a Lisfranc injury located at the Lisfranc joint complex which is best seen on the AP and oblique views. The Lisfranc ligament stabilizes the foot therefore, a missed injury can lead to great damage to the foot cartilage. Arthritis and collapse of the arch are complications of a missed Lisfranc injury.

  • The Lisfranc ligament complex consists of a dorsal, interosseous, and plantar ligament (see Figure 3).
  • The medial borders of the 2nd metatarsal and 2nd cuneiform, also named intermediate cuneiform, should be aligned on the AP view. The medial border of the 3rd metatarsal and 3rd cuneiform should align on the oblique view.
  • If there is any disruption or widening of the 1st-2nd metatarsal space, a Lisfranc injury should be suspected.
  • This injury typically results from an axial load to a plantarflexed foot or a crush injury.

 

Figure 3: The Lisfranc ligament complex. Red: Dorsal ligament, Blue: Interosseous ligament, Green: Plantar ligament (6)

 

Examine the midtarsal joints for good alignment to assess for appropriate integrity of the corresponding ligaments.

 

Figure 4: Midtarsal joints (5)

 

5. Additional View Needed?

  • Weight bearing foot AP or lateral view if a Lisfranc injury is suspected. Some institutions will acquire a foot CT instead as it is more sensitive for this type of injury and could also unveil subtle findings that would be missed on a plain radiograph.
  • Os calcis view if there is suspicion for a calcaneal fracture.
    • Around 60% of tarsal bone fractures are associated with the calcaneus.

The Bohler’s angle is used on plain radiographs to assess the presence and severity of these fractures. This angle is measured on the lateral view and results from an initial line drawn from the highest point of the anterior process of the calcaneus and the posterior articular facet (line 1) followed by a line joining the highest point of the posterior articular facet with the calcaneal tuberosity as shown in figure 5. A normal Bohler’s angle ranges between 20 and 40 degrees, any value below should raise suspicion for a calcaneal fracture.

 

Figure 5: Bohler’s angle (6)

 

Pitfall

Apophysis of the proximal 5th metatarsal: Appears from age 10 and 12 in girls and boys, respectively and generally fuses within 2-4 years. This apophysis is located laterally and oriented parallel to the shaft as seen in Figure 6. Do not mistake this with an avulsion fracture or an os peroneum (accessory bone) which are often oriented transversally.

 

Figure 6 : Apophysis of the proximal 5th metatarsal (4)

Figure 7 : Avulsion fracture of the 5th metatarsal (9)

 

Bottom Line

Foot radiographs are often utilized in clinical practice and especially in the emergency department. Research shows that having a systematic approach improves the diagnosis accuracy and therefore can reduce the incidence of inappropriate management of foot injuries (8).

 

References

  1. https://radiopaedia.org/articles/foot-radiograph-an-approach
  2. https://www.aliem.com/emrad-foot-x-ray/
  3. https://www.researchgate.net/figure/Oblique-radiographs-of-a-Lisfranc-injury-and-normal-right-foot-The-rotation-and-loss-of_fig1_262265287
  4. https://radiopaedia.org/articles/apophysis-of-the-proximal-5th-metatarsal?lang=us
  5. https://radiopaedia.org/articles/midtarsal-joint?lang=us
  6. https://radiopaedia.org/articles/bohler-angle-2?lang=us
  7. https://radiologyassistant.nl/musculoskeletal/wrist/foot-1#foot-case-1-distortion
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964112/
  9. https://www.mdedge.com/familymedicine/article/100121/pain/twisted-ankle

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Nursemaid’s Elbow

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Nursemaid’s Elbow

Medical Student Pearl

 

Erika Maxwell

@ErikaMaxwell

Memorial University Class of 2023

Reviewed by: Dr. David Lewis

Case

A 10-month-old female is brought into the Emergency Department by her mother with a left arm injury. The infant had a fall from standing and the mother reached out to grab her and caught her left forearm. After the incident, the patient’s mother noticed that the infant was no longer using the arm. The child has no medical history and is not taking any medications. She is vitally stable.

On exam, the child’s left arm is limp and extended at her side. She is using her right arm and hand exclusively, including to grasp for items on the left side of her body (pseudoparalysis). There is no deformity, erythema, edema, or ecchymosis. The arm and hand are neurovascularly intact (strong brachial pulse, pink and warm).

Differential Diagnosis

  • Nursemaid’s elbow/pulled elbow/radial head subluxation
  • Elbow fracture
  • Wrist fracture or soft tissue injury
  • Shoulder dislocation

Background

A pulled elbow occurs most frequently in young children with the median age for presentation being 2 years [1]. The reason for this is debated in the literature with some sources saying that the annular ligament is weaker in children [2] and others saying that the radial head is smaller [1], both resulting in a less stable joint.

The most common mechanism of injury is axial traction (i.e. pulling on the arm or hand), but falls or rough play may also be responsible [2].

Anatomical Context

The annular ligament holds the radial head in place next to the ulna. When axial traction is applied by pulling the forearm or hand, the radial head may move underneath the annular ligament and trap it in the radiohumeral joint, against the capitellum [1].

Figure 1: The arm on the left displays a normal elbow, whereas on the right the radius is subluxated and trapping the annular ligament against the capitellum [3].

Signs and Symptoms [3]

  • Pain at elbow
  • Pseudoparalysis of injured arm
  • Extension or light flexion of injured arm, often pronated

Diagnosis and Management

A full examination of the upper limb is required. Leave obviously swollen or deformed areas until the end. Palpate the clavicle, humerus, forearm and gently move the joints (shoulder, wrist, and lastly elbow). Pulled elbows rarely result in joint swelling. If this is present an alternative diagnosis should be considered (e.g., supracondylar fracture).

If a pulled elbow is the only likely diagnosis, then it may be reasonable to proceed to a subluxated radial head reduction manoeuvre. However, when the history is not clear (e.g., unwitnessed mechanism involving siblings or a fall), then it is much safer to perform further diagnostic tests prior to manipulation. These include radiograph of the elbow to rule out fracture or elbow ultrasound to rule out joint effusion [4].

Reduction Technique

 This is done by supporting the elbow with one hand and using your other hand to move the patient’s arm through the recommended maneuvers. There are 2 different maneuvers to try, and they may be used alone or in combination [1-3,5].

  • Supinate the child’s forearm with your hand and flex the elbow

 

Figure 2: Demonstration of the supination/flexion maneuver [5]

  • Hyperpronate the child’s forearm

Figure 3: Demonstration of the hyperpronation maneuver [5]

Some research has indicated that the hyperpronation maneuver may be more effective and less painful for the patient [2,6], so it may be worth attempting this maneuver first.

If the maneuvers are successful, you may hear a click from the radial head as it moves back into place. The child may briefly cry as the subluxation is reduced. Movement recovery can take anywhere from a few minutes to several hours, but usually occurs within 30 minutes. The greater the delay from injury to presentation and subsequent reduction, the longer it will take for post reduction return to normal movement [2].

If a click is heard or felt during the manoeuvre it can usually be assumed that reduction has occurred. Ideally, it is recommended that the child remain under observation until normal movement returns. However, if delayed, it is reasonable to discharge the child with advice to return.

In any case where an x-ray or ultrasound has not been performed and the child does not rapidly start using their arm post manoeuvre, then imaging is required prior to any further manipulation.

Prognosis

Although a pulled elbow does not result in a permanent injury, it is important to inform the family that their child will be vulnerable to recurrent pulled elbows in the affected arm. Up to 27% of patients with a pulled elbow may experience a recurrence [7-8].

Case continued:

Based on the patient’s history and physical exam, she was diagnosed with a pulled elbow. Using the supination and flexion maneuver followed by the hyperpronation maneuver, an audible click was elicited from the patient’s elbow. Shortly thereafter, she began using the arm again as if no injury had occurred and was discharged home.

Key points:

 

  1. A pulled elbow is a common upper limb injury in young children presenting to the Emergency Department
  2. Careful assessment may preclude the need for diagnostic imaging however if in any doubt further investigation should be performed prior to manipulation. Many physicians will never forget the time they used a pulled elbow reduction technique in a child with an unexpected supracondylar fracture
  3. HYPERPRONATE and/or SUPINATE & FLEX!
  4. Recurrence is common

References

  1. Aylor, M., Anderson, J., Vanderford, P., Halsey, M., Lai, S., & Braner, D. A. (2014). Reduction of pulled elbow. New England Journal of Medicine, 371(21), e32.
  2. Wolfram, W., Boss, D., & Panetta, M. (2018, December 18). Nursemaid Elbow. Medscape. Retrieved September 6, 2022, from https://emedicine.medscape.com/article/803026-overview#a5
  3. Boston Children’s Hospital. (2021). Nursemaid’s elbow. Retrieved September 6, 2022, from https://www.childrenshospital.org/conditions/nursemaids-elbow
  4. Varga, M., Papp, S., Kassai, T., Bodzay, T., Gáti, N., & Pintér, S. (2021). Two- plane point of care ultrasonography helps in the differential diagnosis of pulled elbow. Injury, 52(1), S21-24.
  5. Kilgore, K., & Henry, K. (2021). Nursemaid’s elbow. Society for Academic Emergency Medicine – Clerkship Directors in Emergency Medicine. Retrieved September 6, 2022, from https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/peds-em-curriculum/nursemaid%27s-elbow
  6. Lewis, D., Argall, J., & Mackway-Jones, K. (2003). Reduction of pulled elbows. Emergency Medicine Journal, 20, 61-62.
  7. Schunk, J. F. (1990). Radial head subluxation: epidemiology and treatment of 87 episodes. Annals of emergency medicine, 19(9), 1019-1023.
  8. Teach, S. J., & Schutzman, S. A. (1996). Prospective study of recurrent radial head subluxation. Archives of pediatrics & adolescent medicine, 150(2), 164-166.
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Pediatric Hip Dislocation & Reduction

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Pediatric Hip Dislocation & Reduction

Resident Clinical Pearl (RCP) – November 2022

Dr. Nick Byers , R2 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed/Edited by Dr. Brian Ramrattan

Case:
A 10 year old presents to the local emergency department after playing with their sibling. The child was “tackled” from behind. A history and physical exam inform you that the child has been healthy until now with a completely uneventful childhood. They are normal, healthy body habitus and laying on their right side, a pillow between their flexed left knee & hip, and straight right leg. This is the only position of comfort for the child. Neurovascular exam is normal and the child refuses to let you move the leg at all. Foot and ankle move normally. Xrays were obtained promptly. A dislocated hip was readily identified (note the arrow sign below).

Greater than 85% of traumatic pediatric hip dislocations are posterior. Male children are at a greater risk by a 4:1 ratio, and in younger patients, they often occur with minimal force, whereas older children tend to require much greater forces due to the strength of structures surrounding the joint. Fractures can be an associated injury, though it was not in this case. A general triad to consider when evaluating for posterior dislocation is an adducted, shortened, and internally rotated leg as seen below:

Treatment:

A simple dislocation should be treated with closed reduction under sedation, ideally within six hours of injury to reduce the risk of osteonecrosis of the femoral head.

Reduction techniques:

There are many reduction techniques discussed in the literature. Most involve in-line traction of the femur with abduction and external rotation as the leg lengthens, with counter-traction (or downward pressure) placed on the pelvis. This allows for the femoral head to enter the acetabulum gently.

A quick review of technique with attending staff present on shift included the following three options:

  1. The Allis maneuver (https://www.youtube.com/watch?v=zmk3vafjAd4): The physician stands on the stretcher with arms hooked under the flexed knee & hip (both at 90o) on the injured side and an assistant provides downward pressure on the pelvis. Hip extension and external rotation can be applied as the hip reduces.

2.  The Captain Morgan technique (https://www.youtube.com/watch?v=lQMWaFX-MeQ&t=6s): The physician flexes the injured hip and knee to 90o and places their foot on the stretcher at the injured hip of the patient, their knee under the patients. They then grasp the patient’s leg with one hand under the popliteal fossa and one at the ankle. With counter-traction/downward pressure on the pelvis by an assistant, the physician plantar-flexes their foot to put traction on the patient’s femur. External rotation and abduction can be applied with the lower leg as the hip is reduced.

3. The cannon technique: The stretcher is raised and the patient’s knee and hip are flexed to 90o with the popliteal fossa sitting directly over the physician’s shoulder, hands on the patient’s ankle (while facing the patients feet). An assistant stabilizes and provides downward pressure on the pelvis. The physician slowly stands up straight providing in-line traction on the femur until the hip is reduced.

Case Conclusion:

Once x-rays confirmed a posterior hip dislocation, closed reduction under sedation in the emergency department was performed by a resident and staff physician using the cannon technique. Post-reduction films and repeat neurovascular exams were normal and follow-up with orthopedics was in place before discharge home.

Post reduction film:

References:

https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/hip-dislocations

https://www.emnote.org/emnotes/captain-morgan-hip-reduction-technique

CASTED course manual, Arun Sayal

Traumatic hip dislocation during childhood. A case report and review of the literature. American Journal of Orthopedics (Belle Mead, N.J.), 01 Sep 1996, 25(9):645-649

https://usmlepathslides.tumblr.com/post/64398003332/posterior-hip-dislocation-posterior-hip

https://posna.org/Physician-Education/Study-Guide/Hip-Dislocations-Traumatic

https://www.ochsnerjournal.org/content/18/3/242/tab-figures-data

https://coreem.net/core/hip-dislocation/

https://westjem.com/case-report/emergency-physician-reduction-of-pediatric-hip-dislocation.html

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Cunningham Technique for dislocated shoulder reduction

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Cunningham Technique for dislocated shoulder reduction: A Resident Clinical Pearl

Rebecca Fournier, PGY1 

Family Medicine, Dalhousie University

Reviewed by Dr. Chris Doiron

Copyedited by Dr. Mandy Peach

Case

38yo woman presenting with right shoulder pain after falling on ice. Unable to adduct right arm across body. Pain is minimal when resting quietly. Xray confirms anterior dislocation. You recently read about a sedation sparing technique to reduce her shoulder and decide to attempt it.

The Cunningham technique has been shown to be an effective and simple method to reduce a dislocated shoulder. The technique is based on the theory that the humeral head remains outside the glenoid fossa due to tension in the muscles surrounding the shoulder, primarily the biceps. Without the use of sedation or analgesia, the Cunningham technique relaxes the muscles to encourage self reduction. When used as the first technique of choice, Puha et al (2016) found a success rate of 76.9 compared to more traditional methods at 87%+. However, attempting Cunningham technique first allowed avoidance of sedation and was not found to increase pain or duration of hospital stay.

Cunningham Technique

A. Patient Selection and Preparation

1. Ideal patient is calm, in minimal pain, able to take direction, understands and willing to participate in procedure.
2. May consider Ativan 0.5 to 1 mg prior to procedure with goal for calm, thoughtful patient able to participate in the reduction. In most cases, Ativan is not required for a successful reduction

B. Patient position

1. Performed with awake, seated patient. Encourage good posture to maximize success
2. Patient and examiner sit opposite one another eye to eye
3. Patients arm position

a. Held adducted at side: critical to success, may be limiting if patient uncomfortable in this position or body habitus restricts adduction at the side.
b. Elbow flexed to 90 degrees

4. Examiner position
a. Examiner rests one hand firmly on top of the patient’s dorsal forearm, applying downward pressure
b. Opposite hand will perform massage aspect of technique

C. Technique
1. Examiner applies gentle, steady pressure downward on dorsal forearm
2. With free hand, examiner massages upper extremity proximal muscles

a. Start at deltoid and trapezius
b. Move distally to biceps and triceps

3. As the patient’s musculature begins to relax, some may experience apprehension.

a. Patient positioning: an awake, seated patient. Encourage good posture with shoulders up and back + chest pushed forward to maximize success.

b. Gently reassure patient that this sensation indicates progress and continued relaxation is key to success
c. Premedication with Ativan prior to procedure may additionally facilitate this transition

4. Anticipate Shoulder to spontaneously relocate

a. May take as long as 15 minutes to relocate
b. Often times an audible “clunk” is not heard, check often to verify if reduction has been successful

5. Confirm reduction with post procedure xray

Take away points:

– Requires no sedation (requires awake patient!) or analgesia
– Pick the right patient! Must be calm, able to take direction, willing to participate, and trust provider
– Attempting Cunningham procedure first avoids risks of sedation and analgesia without increasing length of stay
– Cunningham method is all about positioning and relaxation; let the humeral head find its way back to the glenoid. Check out the videos for a step by step by visual.
– Confirm reduction with post procedure xray

 

References

Gudmundsson TH, Bjornsson HM. [Reduction of shoulder dislocation with the Cunningham method]. Laeknabladid. 2017 Sep;103(9):373-376. Icelandic. doi: 10.17992/lbl.2017.09.150. PMID: 29044033.

Puha B, Gheorghevici TS, Veliceasa B, Popescu D, Alexa O. CLASIC VERSUS NOVEL IN REDUCTION OF ACUTE ANTERIOR DISLOCATION OF THE SHOULDER: A COMPARISON OF FOUR REDUCTION TECHNIQUES. Rev Med Chir Soc Med Nat Iasi. 2016 Apr-Jun;120(2):311-5. PMID: 27483710

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Paediatric Supracondylar Fractures

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Paediatric Supracondylar Fractures – A Medical Student Clinical Pearl

 

Reviewed by Dr. Joanna Middleton

Copyedited by Dr. Mandy Peach

Christine Crain (She/Her), CC3
Dalhousie Medicine MD Candidate, Class of 2022

Relevant Case:

On a Saturday, a three-year-old presented to the emergency department with his mother. He’d been playing in the backyard with his older sister who was on their swing. Unfortunately, the boy walked in front of the swing and was hit by his sister. He fell onto an outstretched hand and immediately began to cry and hold his elbow.

Problem:

There are two kinds of Supracondylar fracture; extension, which accounts for up to 95% of these fractures; and the far less common flexion fracture which occurs almost exclusively in older adults.

When a paediatric patient falls into an outstretched hand, the olecranon engages with the fossa, then acts as a fulcrum hyperextending the elbow, punching the olecranon through the relatively thin and weak supracondylar region of the humerus.

Figure 1: Case courtesy of Dr Samir Benoudina, Radiopaedia.org, rID: 39938

The Gartland classification (Fig.1) of supracondylar humeral fractures are based on the degree and direction of any displacement where Type 1 fractures imply little (1b) to no displacement (1a). Type 2 fractures displace the anterior humeral line (Fig.2) but leaves the posterior cortex intact; while type 3 fractures are completely displaced.

Figure 2: The anterior humeral line should pass through the middle third of the humeral capitulum. Case courtesy of Dr Samir Benoudina, Radiopaedia.org, rID: 41167.

Since these fractures commonly occur in children, learners especially need to be aware of the ossification centers within the elbow to be certain that they’re recognized as normal anatomy and not additional fractures. The age of the child should help you to estimate, with the help of a handy mnemonic, which ossifications centers should be visible on radiograph:

Figure 3: Case courtesy of Leonardo Lustosa, Radiopaedia.org, rID: 80555

In our case, with a three-year-old male, we would expect to see the Capitellum and Radial Head, but no other centers. We know any “fragments” in these areas are not additional fractures.

Most commonly in supracondylar fractures, there are other signs we look for that may indicate injury to the cartilage and forming bone:

  • Sail Sign shows a joint effusion under the Anterior fat pad (Fig. 4)
  • Posterior Fat Pad sign is the same, only on the posterior aspect of the elbow (Fig. 4)
  • And, as noted above, the Anterior Humeral Line should intersect the middle third of the Capitellum (Fig. 2)

Figure 4: Showing both Anterior and Posterior fat pad sign. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 13527

Finally, given the number of vascular/neural structures that pass through the elbow, what complications are there to be aware of? As with all fractures, there is a risk of non/malunion, this is a relatively low risk however and is beyond the scope of this pearl.

Vascular complications include Volkmann’s contracture which can occur with injury to the brachial artery. This can result in a volar compartment syndrome leading to fibrosis and contracture of flexor muscles.

Finally, injury to any of the nerves that travel to innervate the hand/forearm can occur. Innervation through the Radial, Median (as well as the Anterior Interosseous nerve), and Ulnar nerves can be verified by a few quick and easy maneuvers as seen in Figure 5.

Figure 5: Innervation of the hand for the purposes of nerve injury screening.

Case Resolutions:

Inspection prior to radiographs showed intact sensation, brisk capillary refill with strong distal pulses, and ongoing ability to move joints below the injury. He was sent for radiographs which reported a supracondylar fracture. We casted his elbow and sent him for follow up to the Ortho fracture clinic the following week.

Conclusion

While learners may initially think ossification centers of the elbow are fracture fragments, using CRITOE they will be able to rule out joint involvement. This will allow you to move more quickly onto other radiographic signs of fracture.

References

  1. https://radiopaedia.org/articles/supracondylar-humeral-fracture-2
  2. https://radiopaedia.org/articles/gartland-classification-of-supracondylar-humeral-fractures
  3. https://radiopaedia.org/articles/anterior-humeral-line
  4. https://radiopaedia.org/articles/elbow-ossification-mnemonic
  5. https://radiopaedia.org/articles/sail-sign-elbow-1
  6. https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric

 

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