Clinical Case 111: Toddler’s Tibia Tale

Another quick ultrasound case.

I usually work nights and weekends – and that means that we have no onsite Xray services.  Hence there is always a reason to use ultrasound to enhance our diagnostics!  In fact if you are coming to SMACC Chicago in June this year – you can hear me prattle on about ultrasound in ED. Chris Nickson has given me the title: “No Xray, No Problem!” to talk on… and I cannot wait.  The real reason I enjoy working after hours – I can practice the way I like – using US in place of Xray.  To me that is a heap of fun and very satisfying!

So onto today’s case.

3 year old girl is brought into the ED one Sunday morning.  She was playing with her older cousins at aunty’s house last night when there was a scream and then silence from the bedroom.  Her aunt went into the room and found her crying and holding her leg.  She was carried out and put to bed.

Fast forward to the next morning – and she is still not wanting to walk.  Refuses to put her foot onto the ground, insisting on being carried.

She is well, afebrile, no other symptoms.  She isn’t really yet developmentally able to localise her exact site of pain – but is clearly upset when I touch her lower leg.  There is no lesion, wound or puncture to the sole of the foot and her hip, knee and ankle all move well without much discomfort.

So – being me and it being a Sunday… ultrasound is indicated.

Now be warned – this is outside the realm of “current practice” although there are a handful of case studies looking at long bone fractures in kids with ultrasound.  Most show it is useful.  However toddler’s fractures are subtle – very subtle.  Even with a solid history and a good Xray it can be hard to see those spiral cracks.

So what did our patient’s tibia look like?

tibia fract

Well it is subtle.  This image is the result of a few minutes searching.  It is very easy to miss subtle fracture on ultrasound.  One really needs to be slow and methodical

 

Here is the plain film for comparison:

tib fract toddler The US image here is profiling the anterior surface of the tibia, the fracture was not detectable on lateral views.

  1. So my learning points from this case:
  2. (1)  that one needs to be careful and methodical
  3. (2) Use the contralateral limb for comparison – there are a heap of growth plates etc
  4. (3) Call any subtle anomaly if you see it – confirm on Xray if uncertain

Casey

Clinical Case 111: Toddler’s Tibia Tale

Another quick ultrasound case.

I usually work nights and weekends – and that means that we have no onsite Xray services.  Hence there is always a reason to use ultrasound to enhance our diagnostics!  In fact if you are coming to SMACC Chicago in June this year – you can hear me prattle on about ultrasound in ED. Chris Nickson has given me the title: “No Xray, No Problem!” to talk on… and I cannot wait.  The real reason I enjoy working after hours – I can practice the way I like – using US in place of Xray.  To me that is a heap of fun and very satisfying!

So onto today’s case.

3 year old girl is brought into the ED one Sunday morning.  She was playing with her older cousins at aunty’s house last night when there was a scream and then silence from the bedroom.  Her aunt went into the room and found her crying and holding her leg.  She was carried out and put to bed.

Fast forward to the next morning – and she is still not wanting to walk.  Refuses to put her foot onto the ground, insisting on being carried.

She is well, afebrile, no other symptoms.  She isn’t really yet developmentally able to localise her exact site of pain – but is clearly upset when I touch her lower leg.  There is no lesion, wound or puncture to the sole of the foot and her hip, knee and ankle all move well without much discomfort.

So – being me and it being a Sunday… ultrasound is indicated.

Now be warned – this is outside the realm of “current practice” although there are a handful of case studies looking at long bone fractures in kids with ultrasound.  Most show it is useful.  However toddler’s fractures are subtle – very subtle.  Even with a solid history and a good Xray it can be hard to see those spiral cracks.

So what did our patient’s tibia look like?

tibia fract

Well it is subtle.  This image is the result of a few minutes searching.  It is very easy to miss subtle fracture on ultrasound.  One really needs to be slow and methodical

 

Here is the plain film for comparison:

tib fract toddler The US image here is profiling the anterior surface of the tibia, the fracture was not detectable on lateral views.

  1. So my learning points from this case:
  2. (1)  that one needs to be careful and methodical
  3. (2) Use the contralateral limb for comparison – there are a heap of growth plates etc
  4. (3) Call any subtle anomaly if you see it – confirm on Xray if uncertain

Casey

Clinical Case 110: Sepsis, Scans and Surgeons

Here is a case that may keep you guessing.  One for the US nerds.  Here we go:

25 year old tourist – visiting the town, she has been backpacking for 6 months and the history is a little vague… but basically she thinks she may have had a miscarriage about 5 months ago.

She had a positive pregnancy test and two weeks later developed pain and PV bleeding.  Didn’t see a doctor as she had no travel insurance…  the pain settled and she thinks she may have passed some large clots  – anyway the symptoms settled and she carried on her travels.  No imaging was done.

Fast forward to now – 5 months later.

The history is of 24 hours of lower ado pain. The pain started in the left iliac fossa.  Was well localised but has since become more generalised – on examination she is guarding and has clear peritonism across the lower belly.  Certainly she is more tender on the left.  She is febrile (39.8 C = 103.6 F), tachycardia 110 and has a BP of 90/60.  She denies any recent PV loss, discharge or urinary symptoms.  Her bowels were OK until yesterday – no motion since the pain started.  A VBG shows a mild, compensated metabolic acidosis, normal lactate.

He UA shows some pyuria but no nitrites.  And the B-hCG is…..   [drum roll] .. negative.

So in summary – a 25 yo lady who may have had a spontaneous miscarriage 5 months ago now presents with a sepsis picture, left iliac fossa pain and peritonism.  We need a scan!  So I will show you a series of 6 TV US images now and let you interpret them…  here we go.   [I have added captions to orient you if you are not familiar with TV scan which can look a bit weird to the uninitiated ]

I think I will let this case linger here for a few days.  Would really love to hear your thoughts on these images, the possible diagnoses and where to next!

Of course I will tell you what the final outcome and diagnosis was – but first lets see what you think of these images in this scenario.

Comments please.  Are you a super sleuth with a scanner?

Casey

Right ovary on TV

Right ovary on TV

Longitudinal pelvis view

Longitudinal pelvis view

Left pelvis adnexa

Left pelvis / adnexa

Left ovary

Left ovary

Left pelvis mass long.

Another look at the left pelvic mass

Being A Doctor’s Doctor – Penny Wilson and Geoff Riley

Have you ever treated a fellow doctor?  How did it feel?  Did you feel confident or intimidated?

Consulting and treating our colleagues can be really tricky.  The dynamics seem a little alien, there is a huge risk of assumption leading to errors and of course there is always the nagging doubt that you may need to go against their wishes in some circumstances.

Dr Penny Wilson @nomadicgp – a regular in the O&G corner of Broome Docs and now the co-creator of the Bit & Bumps podcast has chipped in this week.  She has interviewed Prof. Geoff Riley – former rural GP and Psychiatrist – who was until recently my boss at the Rural Clinical School in Western Australia.  Geoff has developed a practice over the years as a doctor’s doctor.  He has treated many fellow doctors including some with significant impairment.

So sit back and relax, grab a cuppa and listen to this fascinating discussion about how we ought to approach being a GP to another doctor – and also how we can be better patients when we go along to see our own family doctor.

Yes – we should all have a GP.  Do you see one? If not – I would love to hear why – hit me on the comments below.

Onto the podcast DOWNLOAD HERE

Casey

SMACC Chicago – it’s heating up

Greetings readers

I have been on a bit of R&R on the run into Xmas and trying to avoid the Internet for a few weeks!

Today though I have come out of hibernation to remind you that the biggest and brightest conference is coming soon… in June 2015.

That may seem like a long way into the future – but the competition for tickets, workshops and hotels is getting tight.

I know that you will seriously regret leaving your planning too late – so get on over to the smacc.net.au website now and register for the conference. Check out ht awesome line up of speakers, workshops and social program.

I have just received a prompt from the organising committee to help me sharpen up my act and together we will make SMACC Chicago to most entertaining and engaging medical event that the world has ever seen!

Most importantly – my favourite part of this awesome event is the chance to meet you all, its so much fun to chat live after all your contributions to the comments and Tweets.  So come on aver and say “Hi”

Casey

SMACC PROMO

The Birthday Bet

I am working on a post about risk and decision-making and I need your help.

I am trying to get a feel for the risk numeracy of the average doctor – I realise that none of my readers is “average” but please take the time to read the following scenario and give me an honest answer.  Please try to avoid Googling the “right” answer – I am after your gut feeling.  I want to know if this were you – and you had to take a guess what would you say?  It is not about the maths – it is about how doctors think…  yes I am data mining your brains.  Sorry.  That is the sort of thing I do for fun on nights here in Broome!

OK here is the scenario;

You are invited to the Hospital Xmas Party by a nice young nurse.  Unfortunately they tell you the wrong time – so you turn up in you fancy dress Chicken Suit an hour early.  Not sure what to do – you decide to engage in idle banter with the Hospital Tea Lady who is carefully arranging her sausage rolls on a long table.  After 5 minutes you discover that you both lived on the same street in Wagga Wagga – although she was there in the 1950s, 30 years before you were born.  Nice coincidence!.

After 20 minutes the conversation stalls a bit, and during and awkward silence she proffers the following bet:

I’ll bet you that there are two people coming tonight who share the same birth date – not necessarily the same year – but the same date eg. the 6th of May…

Of course there are 500 people coming to the party – so it is a pretty easy bet.

OK, to make it interesting.  Lets ask each person as they arrive their birthdate.  And see how long it takes before we have a match i.e.  a pair with the same Birthday.

OK – sure.  How many people do you think?  Tell me how many people need to arrive at the party before it is a better than 50:50 bet that there will be a shared birthday?  That is – when would it be in your favour to take the Tea Lady’s Bet

Thanks for that – promise I will share the results soon.

Casey