Fracture Fridays: Bony complications of repeated shoulder dislocations

The Case

After successfully reducing the shoulder of a young athlete – his fourth, your first. He says the the last 2 times he dislocated it was reduced by his team trainer on the sidelines. You obtain XRays and note the following.

Courtesy of Wikipedia

Courtesy of Wikipedia

The Diagnosis

This is a Bankart lesion. Note the abnormality in the inferior third of the glenoid labrum (in the annotated XRay). With repeated anterior-inferior shoulder dislocations a groove or pocket forms in the front of the glenoid. XRays have sensitivity/specificity in the 60%s with MRI being 96% sensitive and 100% specific according to Cicak et al, J Ultrasound Med, 1998.

Courtesy of Wikipedia

Courtesy of Wikipedia

It is often accompanied by a Hill Sachs lesion, which is a concave cortical depression on the humeral head. The latter is also seen in patients with multiple dislocations, and occurs when the humeral head forcefully impacts against the anteroinferior glenoid rim (seen below).

Courtesy of Wikipedia

Courtesy of Wikipedia

Management

Both of these findings in isolation (or together), and especially in the context of multiple dislocations are basically a signal to send the patient to Ortho. The management of a Hill-Sachs lesion is repair when there is shoulder instability. Bankart lesions are also best managed by a surgeon.

The post Fracture Fridays: Bony complications of repeated shoulder dislocations appeared first on PEM Blog.

ECG of the Week – 21st April 2014

This week's ECG is from a 58yr old male brough in by ambulance following a polpharmacy overdose. 

Vital signs - BP 104/75 RR 9 T 37.2 Sats 96% GCS 6 (E=1 M=4 V=1 ) BSL 5.9


Click to enlarge



VAQ Corner

A 58yr old male is brough to your Emergency Department by ambulance following a polpharmacy overdose, agents unknown.
Vital signs: 




  • BP 104/75 
  • RR 9 
  • T 37.2 
  • Sats 96% 
  • GCS 6 (E=1 M=4 V=1 ) 
  • BSL 5.9
a) Describe and interpret his ECG (50%)
b) Outline your management (50%)


Why don’t we talk about patient satisfaction scores more honestly?

It’s a perfect storm. Get too hostile about patient satisfaction scores and you look like a jerk. But, are they really truly good for patients? Aside from MAYBE corralling the most out of touch and horrible physicians from acting out, who are they helping?

I don’t think they’re helping me. And, my scores are typically very high. And, I don’t think they’re helping our patients. Not the way they should. A great article here tells us it’s worse for patients, more expensive, and maybe it’s undermining the doctor patient trust…

http://archinte.jamanetwork.com/article.aspx?articleid=1108766

 


So do we call them extreme infections?

It’s no secret that the “extreme athlete” industry continues to steamroll mainstream athletics. This isn’t a new trend, as evidenced by the fact that this review article is from 2007. Sorry for making everyone feel old by reminding them that CrossFit® is now 14 years old.

Anyway, extreme athletics involves taking classic sports and making them longer distances, more difficult, in austere locations, or combining multiple events into one. You also are required by law to say “extreme” in a loud, guttural voice. Due to the terrains, climates, and exotic locales involved in these sports, the extreme athlete is exposed to infections the typical (normal?) athlete isn’t. These are broken down in the article into parasitic, aquatic, tick-borne, and zoonotic infections. It’s not an exhaustive list, but is fairly extensive and thus only the surface will be scratched here.

Parasitic infections are important because diarrheal illness obtained almost everywhere except Southeast Asia is more likely to be parasitic than bacterial. Malaria gets emphasized by the article and should certainly never be missed. Certainly, fever and eosiniphilia in any returning traveller needs to be investigated further for all parasites. Other causative agents described are amebae, nematodes, and cutaneous larvae.  The last one is interesting, as athletes are more likely to have broken skin and thus be susceptible to myiasis than typical tourists. An important point is that you must be aware of the endemic parasites where the athlete is intending to travel, and understand prevention, diagnosis, and treatment.

Ingested water can also be problematic, as Giardia, Cryptosporidium, and Schistosoma are common in the surface water of many areas. Since the incubation period can be as long as 40 days, good history taking is important. Schistosoma in particular can be nasty, with pulmonary, urologic, hepatic, and even neurologic manifestations, so one does not want to miss this infection. Again, treatment is organism specific.

Aquatic infections are common as well. These can come from any break in the skin that is exposed to water, including but not limited to bites, coral injuries, and stings. These must all be irrigated copiously, but empiric antibiotics should not be started. If a secondary infection does occur, due to atypical organisms, cultures should be obtained before giving antibiotics. They mention considering delayed wound closure, but this is falling out of favor in the years since the article and I wouldn’t recommend it unless there is serious contamination and no irrigation media available.

Tick-borne diseases, such as Lyme, Rocky Mountain Spotted Fever, babesiosis, and ehrlichiosis are yet another problem the extreme athlete has to consider. Using DEET is probably your best prevention, and whole body examination after potential exposure is a must. Infection usually takes 24-48 hours of attachment, so early detection is key. Just don’t do anything silly like use gasoline, KY, or fire to remove the tick. Use forceps, and get all of it. And as has been discussed, you should prophylax with 200 mg doxycycline if you remove a tick from someone in Lyme endemic areas.

The last grouping of infections is the zoonoses, but only 2 types are mentioned. The first, leptospirosis, can be found in many farm animals and rodents. As it is shed in their urine, it can be acquired from contaminated groundwater. They mention two specific outbreaks, one Illinois triathlon where 12% of the participants (98/834) contracted the disease, and an Eco-Challenge in Malaysia where a whopping 44% of athletes (69/158) had symptoms consistent with leptospirosis. Hantaviruses, usually associated with campers, are mentioned for what is presumably completeness sake. Treatment is supportive at best, although they mention ribavirin treatment based on only one reference.

They finish the article with sound advice on insect repellent, treating drinking water, and obtaining evacuation insurance. It seems as if the authors wanted to ride the “extreme” sports wave by merely discussing tropical and subtropical diseases, as none of these are unique to extreme sports. Sadly, they were trying to be too encompassing and became overly bloated at 15 pages with references. It’s not a bad review article for someone not familiar with travel medicine.

Infectious Disease and the Extreme Sport Athlete
http://www.ncbi.nlm.nih.gov/pubmed/17826196

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Trick of the Trade: Making your own homemade ultrasound gel

UltrasoundKenyaExpertPeerReviewStamp2x200You are spending a month in rural Kenya, doing an ultrasound teaching course. Your enthusiastic participants have been ultrasounding every chance they get. Unfortunately, this has caused your ultrasound gel supplies to dwindle. It will be a month before a new shipment of gel arrives from Nairobi. This gel will cost about $5 per bottle, which is a considerable expense for the local hospital’s budget.

Trick of the Trade: Homemade ultrasound gel

With a few simple and ubiquitous ingredients, you can make your own ultrasound gel to use. 

PIC1

Equipment Needed 

  • Corn starch
  • Water
  • Pot or pan
  • Heat source
  • Empty and clean bottle 

PIC2

Technique

  1. Combine 1 part corn starch to 10 parts water in a pan. Here, we use ¼ cup corn starch to 2 ½ cups water to make about 2 gel bottles full.
  2. Heat this mixture while stirring constantly at medium heat for 5-10 minutes.
  3. When the substance begins to boil, turn off the heat and allow the mixture to cool.
  4. Pour the mixture into a clean, preferably sterilized, container. Here, we use an old commercial ultrasound gel bottle which we placed in boiling water for 10 minutes first.
  5. Ultrasound away! Note that the gel should be used within 48-72 hours for best results. After that, it may begin to separate a bit.

PIC3

Word of Caution

This homemade gel does not have the same bacteriostatic ingredients that are in commercial ultrasound gel. Therefore we do no recommend its use for skin and soft tissue infections.

Expert Peer Review

April 11, 2014

For anyone who has spent time working abroad in a low resource area, you are likely familiar with the utility of ultrasound. It has a wide range of applications, it is easy to use, and there is an increasing number of portable machines available. There are very few ongoing costs associated with the use of ultrasound machines. The exception to this is ultrasound gel.

There is very little published about ultrasound gel alternatives. The 1995 WHO Manual of Diagnostic Ultrasound [1] contains a recipe for making your own ultrasound gel which requires many chemicals not available in most low resource settings. Olive oil has been studied as a feasible alternative [2] but is messy and provides less surface contact between the patient and the probe. Water baths have been looked at but are only applicable to extremity ultrasound [3].

In our recent pilot study [4], we found that a cornstarch-based alternative is at least comparable to commercial gel. Our study, which is a randomized blinded trial (abstract forthcoming at SAEM 2014) found no statistically significant difference between commercial gel and the cornstarch alternative in terms of image quality. The cornstarch-based alternative is an easily created, easily used, extremely inexpensive option that will hopefully make ultrasound more feasible and accessible in low resource settings.”

Reference

  1. Manual of diagnostic Ultrasound [PDF 3.6 MB], 2nd Edition. World Health Organization. 2011. Retrieved Aug 13, 2012 
  2. Luewan S, Srisupundit K, Tongsong T. A comparison of sonographic image quality between the examinations using gel and olive oil as sound media. J Med Assoc Thai. 2007 April; 90(4)624-7. Pubmed
  3. Blaivas M, Lyon M, Brannam L, et al. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Am J Emerg Med. 2004 Nov;22(7):589-93. Pubmed
  4. Binkowski A, Riguzzi A, Fahimi J, Price D. Evaluation of a Cornstarch-Based Ultrasound Gel Alternative for Low-Resource Settings. J Emerg Med. 2013 Nov 12. pii: S0736-4679(13)01064-0. Pubmed
Allison Binkowski, MD, Emergency Physician, Ventura County Medical Center

 

Top image

 

Author information

Christine Riguzzi, MD
Christine Riguzzi, MD
Ultrasound Fellow
Department of Emergency Medicine
Highland General Hospital-Alameda Health System

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