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Re: Bike accident

 
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Re: Bike accident - September 15, 2005 9:13:00 AM   
Dr.Wagner


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Exactly Greg...an anterior fat pad means nothing, an exagerated anterior fat pad means hemarthrosis, a posterior fat pad means hemarthrosis. Both of which means you need to be concerned.
These films are inconclusive and obviously need another view. If still unsure, make clinical correlation and consider CT/MRI depending on time (CTs are alot easier to do and schedule).

For as many xrays that I see on a daily basis, this is not one that I would say "holy crap"...the lines "line up" and this really doesn't give me a boner at all. This is NOT impressive, and these views do not lead to the conclusion of a fracture.
Now, I CAN NOT zoom or use a magnifying glass on this xray which is WHAT HAS TO BE DONE. THis type of view leads to nothing and further examination of the film is needed to clearly identify a fracture.

THink of this, you show an elbow on a "guess where the fracture is" website and people are going to say "oh yeah, look at the sail sign"...it is not profound, at least on my screen, and stick it next to 10 other normal elbows and you would be unimpressed based upon those views only.

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(in reply to Alex Brenner PT MPT OCS)
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Re: Bike accident - September 15, 2005 9:31:00 AM   
FLAOrthoPT

 

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okay let's see the other view.....
drumroll please...

(in reply to Alex Brenner PT MPT OCS)
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Re: Bike accident - September 15, 2005 9:36:00 AM   
Alex Brenner PT MPT OCS

 

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Ok, you asked for it.



I guess this is why we get 3 views of the elbow.

< Message edited by Randy J Moore -- July 22, 2007 11:14:47 PM >


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Alex Brenner, PT, MPT, OCS

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Re: Bike accident - September 15, 2005 10:06:00 AM   
SJBird55

 

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Now, that view has an obvious fracture.

Wags, has the reading of radiographs gone to higher technology levels where you view it on a computer? (The surgeons taught me the "lines line up" saying too.) When I was with the surgeons, they did the radiographs in their office... then it was just that plastic film paper. But... they had this cool little light that they'd put the film up to for closer assessment - of course, there is one tiny little problem with using that bulb - it gets hot! LOL I'm just an unskilled PT, so of course, I wasn't allowed to hold any film in front of it because the joke in the office was that I'd either melt the sucker or burn the joint down. LOL

(in reply to Alex Brenner PT MPT OCS)
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Re: Bike accident - September 15, 2005 11:23:00 AM   
JLS_PT_OCS

 

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Well, there's our expected radial head fracture, but I don't see my much-discussed capitulum fracture. Oh, well, live and learn...

SJ, there are many high-resolution digital terminals available for viewing, enlarging, zooming, etc for films.
J

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Re: Bike accident - September 15, 2005 12:11:00 PM   
chiroortho

 

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The artificiality of viewing less than a complete series leads to interesting comments and a pretty good learning exercise. In real life when a view is missing the rad dept is called and they 'find' the missing view.

When I see patients that have had imaging studies at the hospital I can look them up on the PACS system. The films come up in multiple boxes and I can click on my favorite views (MRI/CT) or just look at the xray study. Never will there be an incomplete study, for all practical purposes. Occasionally there'll be a lousy film but the radiologist usually takes care of that.

I don't know how it's done in the ED but sitting at my desk it's very convenient to be able to manipulate film brightness/contrast, etc.

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Re: Bike accident - September 15, 2005 1:00:00 PM   
SJBird55

 

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Hmm, Jas, guess the technology is there such that it is SJ burn/melt proof!

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Re: Bike accident - September 15, 2005 10:45:00 PM   
Dr.Wagner


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Yeah, by computer I meant at home. The stations in the ED do a bunch of stuff, reversing images etc.

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Re: Bike accident - September 16, 2005 3:45:00 AM   
Alex Brenner PT MPT OCS

 

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PROCEDURE: Three-view right elbow series.

FINDINGS: There is a linear fracture through the lateral aspect of the radial head, without significant displacement. There is elevation of both anterior and posterior fat pads. The humerus and ulna are unremarkable.

IMPRESSION: Radial head fracture with joint effusion.

This patient told me that when she was seen in the ER she had just a little elbow pain. Most her pain was in the wrist. The wrist films were indeed read normal and there is no fracture there. The ER physician failed to examine the elbow. Had he just palpated around the radial head he would have elicited pain and decided to get films. It was missed.




< Message edited by Randy J Moore -- July 22, 2007 11:12:59 PM >


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Re: Bike accident - September 16, 2005 7:44:00 AM   
chiroortho

 

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That's interesting Alex, and reminds me of when I broke my wrist as a kid running over another kid in baseball...I fractured my distal radius but as I recall most of the pain was on the ulnar side, even the swelling. Dr. Coach said it was fine so I kept playing. Next day man was it swollen.

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Greg Priest, DC, DABCO

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Re: Bike accident - September 16, 2005 10:43:00 AM   
Dr.Wagner


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Its that 3rd view that makes it, the "sail sign" is unimpressive, yet disposition is the same. And it really isn't that uncommon at all to have a second injury. The wrist was a distracting injury...I have missed things too when you have multiple injuries. You don't want to, but it certainly happens; Probably happens daily. That is why follow up is so important.
24 hours later, whammo something else really hurts happens ALL the time on trauma.

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Dr. Wagner DO
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(in reply to Alex Brenner PT MPT OCS)
Post #: 31
Re: Bike accident - September 16, 2005 12:21:00 PM   
chiroortho

 

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Yes Dr. Wagner, that's EXACTLY right.

As soon as Alex said that he was withholding the third view we knew that it showed the fracture.

And I knew that you meant your home computer...it goes without saying that you don't have time to look at rehabedge during your ER shift. I wasn't sure if the software in your ED would allow for image manipulation. It is good to know that it does because almost 100% of the time I have to fiddle with brightness/contrast to see what I want to see.

Greg

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Re: Bike accident - September 16, 2005 1:30:00 PM   
jma

 

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That is definitely true.

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Re: Bike accident - September 16, 2005 5:16:00 PM   
Dr.Wagner


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Yeah, I flip, enhance and brighten...but darn it, it has to correlate clinically. I have seen WAY too many hips that MAY be fractured but the woman can do handstands. And the converse is true FAR FAR more often, people who act injured, have no swelling or ecchymosis and have what appears to be a negative film. That sucks.

All in all the disposition is the same, change weight bearing status, perhaps splint, and follow up.

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Dr. Wagner DO
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Post #: 34
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