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DCMC Radiology Newsletter 10:15 “docendo discimus” VOL 2 NO 10 OCTOBER 2015 DCMC Emergency Department Radiology Case of the Month These cases have been removed of identifying information and are intended for peer review and educational purposes only. Welcome to the DCMC Emergency Department Radiology case of the month! In conjunction with our pediatric radiology specialists from ARA we hope you enjoy these monthly radiological highlights from the case files of the Emergency Department at DCMC. These cases are meant to highlight important chief complaints, cases, and radiology findings that PEM Fellow Conference Schedule October 2015 we all encounter every day. 6th - Faculty Development: Simulation....................................................Dr Floyed If you enjoy these reviews we invite you check out Faculty Development: Research..................................................Dr Wilkinson Pediatric Emergency Medicine Fellowship Radiology 7th - 8:15-10:15 Sim: Cardiology.......................Drs Wyrick and Ryan/Sim Faculty Rounds, which are currently offered quarterly and are held 11:15-12:15 TBD with the outstanding support of the pediatric radiology 14th - 9:15-10:15 US: Renal/Abdominal Pathology..................................Dr Boeck specialists at Austin Radiologic Association. 11:15-12:15 Grand Rounds If you have any questions or feedback regarding the 16th - PEM Fellowship Applicant Interview Day Case of the Month format, feel free to email Robert Vezzetti, MD at 20th - Living Well in PEM.........................................................PEM Faculty [email protected]. 21st - 9:15-10:15 PEM Radiology Rounds: Thorax ...Drs Vezzetti/Berg/Lonergan 10:15-11:15 Research Lecture.....................................................Dr Wilkinson 12:15-1:15 PEM Fellowship Research Update This Month: BOO!! Happy Halloween to All! 28th - 9:15-10:15 M&M..............................................................Drs Kienstra and Hill 10:15-11:15 Board Review: GI.............................................................Dr Gorn We haven’t had an ortho case in a while, so............... 12:00-1:15 ED Staff Meeting A young girl who has sustained a knee injury while running 30th - PEM Fellowship Applicant Interview Day at school. This is a very common complaint and which, if Guest Pediatric Radiologist: Dr Gael Lonergan, MD any, imaging tests to order can be confusing, if not scary! DCMC/ARA Additionally, what does one do when they find something All Lectures are at Dell Children’s Medical Center in Command Rooms 3&4, unless otherwise specified. they were not expecting, especially when it is not related Simulations are held at the CEC at University Medical Center - Brackenridge. to the reason an imaging test was obtained in the first Schedule subject to change. place? We’ll also look at some common knee injuries, so read on... Charles Samuel "Chas" Addams (January 7, 1912 – September 29, PAGE 1 1988) was an American cartoonist known for his darkly humorous and macabre characters. Some of the recurring characters, became known as The Addams Family, which first appeared in the New Yorker. Please Note: A special thanks to Dr Robert Schlecter for adding the following teaching points from one of last month’s cases: “Two points... Atresia is a complete obstruction, so presents prenatally or with first feeds. Stenosis canVOL present 2 NO later. 10 Also... The history was so characteristic of SMA syndrome that OCTOBER 2015 consideration could be given to an Ultrasound before CT... It can be dxed on US.” Case History: Ah, the start of school! It’s that time of year where sunburns and insect stings start to fade away and just before the dreaded RSV/Influenza/URI season. Yep, time for some athletic injuries, which are plentiful in the Pediatric Emergency Department. You settle in to your shift as you pick up the first chart, which is a 11 year old female with right knee pain. Apparently she was running at school when she experienced a “pop” in her knee, followed by sudden pain. She was unable to continue running; the athletic trainer at the school applied ice to the knee, but swelling developed and, eventually, began to worsen. By this point she was unable to ambulate without pain, so she was brought into the Pediatric Emergency Department for an evaluation. You note that the vital signs are all unremarkable. She has been in good health, for the most part, but did have a fracture of her left tibia earlier in the year, which was treated by Pediatric Orthopedics at Dell. On examination, you note a child who is in some discomfort, which she states is due to her knee pain. Her knee has some mild generalized edema, but no obvious deformity. The joint appears possibly lax, but this is difficult to assess secondary to pain. Her hip, femur, tibia/fibula, ankle, and foot all appear to be normal. She has strong popliteal, dorsalis pedis, and posterior tibia pulses. She is neurologically intact. She refuses to ambulate secondary to pain, but her mother states she was “limping” when picked up at school. Motrin was given in Triage and the child states that this has “helped a little bit”. The ice pack that was applied at school also helped, but it warm now, so you replace and and begin to ponder how to work up this injury. Does this child need imaging? Is an xray sufficient? Should you proceed to a CT or an MRI? Maybe you could just ask for a Pediatric Orthopedic consult..... Differential Diagnosis: Knee injuries are very common complaints in Pediatrics, so it’s nice to have a good differential when evaluating these patients. Here’s an example: Remember varus and valgus forces from your Mechanism Type Of Injury orthopedics rotation? neither do I. But here is a drawing to help us both keep it straight. High impact trauma (MVC, etc). Knee dislocation, PCL tear Knee “went out” after pivoting. Patellar dislocation; ? osteochondral fx Valgus is a force applied to the Fall with twisting/hyperextension. Tibial spine fx lateral knee. Jumping. Tibial tubercle avulsion fx Varus is a force applied to the Valgus stress. MCL injury or physeal fx medial knee. Varus stress. LCL injury or physeal fx Hyperextension, twisting. ACL injury, tibial spine fx Direct blow/fall. Patellar/osteochondral fx Adapted from: Canty GS and Knapp JF. The Initial AssessmentPAGE 2 and Management of Peditric Knee, Ankle, and Wrist Injuries. “Pop”. ACL injury/patellar dislocation Peditrc Emerg Med Pract. 2008;5(8). Gomez Addams: “Husband to Morticia, if indeed they are married at all... a crafty schemer, but also a jolly man in his own way... though sometimes misguided... sentimental and often puckish - optimistic, he is in full enthusiasm for his dreadful plots... is sometimes seen in a rather formal dressing gown... the only one who smokes.” VOL 2 NO-Charles 10 Addams OCTOBER 2015 It helps to remember, then evaluating children with skeletal injuries, that: “the more immature the patient’s skeleton, the greater the risk for fracture”. There are a few things to remember when evaluated pediatric knee injuries. One good hint is that obtaining an imaging test is usually a good idea prior to performing more detailed examinations of the knee (for example, the various tests for joint or ligamentous injury). There are two well-established guidelines to help decide when to obtain radiographs in pediatric knee injuries: 1. The Ottawa Knee Rule. 2. The Pittsburgh Knee Rule. The Ottawa Knee Rule is most-validated in pediatric patients. Ottawa Knee Rules Pittsburgh Knee Rules Recommend Radiographs If: Recommend Radiographs If: 1. Age > 55 years. 1. Age <12 years or > 50 years. 2. Isolated tenderness of the patella. 2. Age 12-50 years of age with trauma and is unable to 3. Tenderness at the fibular head. to walk 4 weight-bearing steps in the Emergency 4. Inability to flex knee to 90〫. Department without limping. 5. Inability to bear weight immediately after injury and in the Emergency Department. This decision rule has not been validated in patients under 12 years of age, because a states risk factor is age >12 years. In the age range of Studies have found high sensitivities (80%-100%), but low 12-50 years, sensitivity of this rule is 99% and specificity is 60%, in specificities. most studies. You decide to obtain a 3 view knee series, as this patient is <12 years old and, frankly, has a somewhat difficult exam. The results are below: There is an extremely subtle irregularity of the right proximal tibia, best seen on the oblique view. There appears to be buckling of the metaphysis (red arrow). This may extend into thePAGE knee joint3 but it is very difficult to tell. By the way, did you notice the lesion in the femur (blue arrow). Now what? Morticia Addams: “The real head of the family... low-voiced, incisive and subtle, smiles are rare... ruined beauty... contemptuous and original and with fierce family loyalty... even in disposition, muted, witty, sometimes deadly... given to low-keyed rhapsodies about her garden of deadly VOL 2 NO 10 nightshade, henbane and dwarf's hair...” -Charles Addams OCTOBER 2015 Here’s a close up of the oblique view. Very subtle posterolateral buckling. OK, the xrays are suspicious for a fracture. This is not just any fracture, as it may extend into the joint space, which is significant. Further imaging is warranted, especially to evaluate for any joint space involvement. The lesion appears to be a benign non-ossifying fibroma. Standard 3 view radiographs of the knee include: AP view, Lateral view, and Oblique or Patellar views. Other plain radiograph options include: 1. Tunnel/Notch view -> can find loose bodies and osteochondritis dissecans. 2. Stress view -> painful to obtain, but can detect opening of the physis with valgus or varus stess application. What About CT Scanning? CT is very sensitive for fractures and very good at detecting tibial plateau fractures and is often obtained in patients with complex fractures.
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