x-ray of the week

The story is thus: Motorcycle accident...six months ago.  He still can't walk so he came to the doctor.  To start, take a quick look at these normal knee x-rays:

This is his x-ray:

can you spot the difference?

totally dislocated

in diagram form (from crashingpatient.com) 

Normally, a posterior knee dislocation would be a surgical emergency. But, after six months, it was hard to be in a hurry to do anything  It might have to wait for the orthopedic surgeon...and even then there may not be much we can do.

the list gets longer

Thursday clinic had quite a few difficult, mysterious, sad, or just plain unusual cases...

It started with a woman whose co-wife had bitten off half of her bottom lip. This is the second time I have seen a woman whose bottom lip was bitten off by a co-wife. What I want to know is- how do they get close enough to bite each other's lips during a fight? Seems quite difficult to do.

Then, I saw a woman with breast cancer. She had noticed a mass for six months which is a relatively short time here. Often women will wait for over a year before being seen for a breast tumor and by that time the tumor is often necrotic (rotting). Its terrible.

She came because she was starting to have chest and back pain.  Her tumor wasn't rotting, but when I examined her I found two masses. One was central in her breast and the other was fixed to her chest wall just under her collarbone. I listened to her lungs and couldn't hear any breath sounds on the side of the tumor. I tried to ultrasound her lungs. I couldn't see much so I moved to more familiar territory- her abdomen. I looked at a liver to see if the cancer had spread there. This is what I saw:

It took me a little while to figure out that I was looking at a huge malignant pleural effusion (fluid around the lungs) that was pushing the entire liver toward the center of the abdomen. Stage IV cancer. 

On x-ray we could see that part of her third rib had also been destroyed by the cancer. Not much we could do except offer to drain the fluid if her breathing became too uncomfortable.

After that I saw a series of less-acute problems most of which did not belong in the standard American "general surgery" category:

1. An elderly woman who ten days ago "suddenly" couldn't open her jaw. Denied any trauma, etc. She couldn't eat anything that wasn't liquid. I sent her to the operating room to have her jaw re-located. 
2. Man with non-displaced fracture of his 2nd and 3rd metatarsals. We put a short-leg cast on two weeks ago. Can it come off now?
3. Two year old with a fluid-filled mass on the top of her head, there since birth. 

fluid filled congenital skull mass...anyone know what this is?

We saw her one year ago. The mass had grown about 1/2 cm since then but otherwise didn't seem to be causing problems. I tried to ultrasound it to get more information.

I'm not entirely sure how to interpret this...

       4. Man with history of leprosy treated 30 years ago for whom we amputated one of his legs for a chronic wound. I put in a call to our occupational therapist and we gave him the phone numbers for what we think is the only place in the country that makes prosthetics (although I have yet to meet anyone with a prosthetic made here).

      5. Man who was in a fight yesterday and had a deformed nose and jaw pain. Nasal fracture.
      6. Young, breast-feeding woman with a solid breast mass that had eroded through the skin and was exuding milk.
      7. Old lady who was in a motorcycle accident two weeks ago, but had lots of shoulder pain and couldn't raise her shoulder. X-ray:

Her dislocated shoulder

So, my five and a half hour “½ day” of clinic left me with about five days worth of reading topics added to my ever-expanding list:

1.     How to read a shoulder x-ray

2.     How to re-locate a shoulder…after ten days (thankfully the OR staff know how to do this without my help!)

3.     Jaw dislocation 

4.     Midline fluid-filled congenital skull masses. What is it? An encephalocele (brain)? Can you see a connection with the brain on ultrasound? When do you remove or observe?

5.     Operative indications for nasal fractures- when do you have to fix it?

6.     Masses in lactating breasts…eroding through the skin

7.     Chest ultrasound for pleural effusion

8.     Breast mass ultrasound

9.     Pediatric skull ultrasound

10.  Metatarsal fracture management

I was so tired after getting up at six am for teaching rounds that I went home and when I was about to take a nap, had to go do a C-section.

And that is why my reading list just keeps getting longer and longer!

now bones are fun

You know what is amazing?!  Having a real, live orthopedic surgeon in clinic!  Its like being a medical student again. As usual, patients arrive with orthopedic problems that I don't even know how to begin to solve. But this Friday, I was not alone in clinic struggling and trying to figure out what to do. Dr. J was there to help! After asking a some questions, examining the patient, and looking at the x-rays...KAZAM!!! within a few minutes Dr. J would deliver a diagnosis and a plan!

For example, check out this hip x-ray:

We saw many patients with hip pain and x-ray's like the one above. The right hip joint is in bad shape. Too destroyed for a hip replacement. 

But, did you know you could do this?

Same patient, but the head and neck of the right femur bone was removed by Dr. J a couple years ago when he came. Guess what?! She can still walk! She has a significant limp, but is very happy because she doesn't have pain.  Amazing.

Dr. J is here for a couple more weeks and I am looking forward to learning a lot more about bones so they aren't such a mystery when he leaves and I am the orthopedic surgeon again. :)

Friday Clinic

Have I told you that I do NOT like Friday clinic? We alternate Friday clinics so that the surgeon that is taking weekend call also does clinic on Friday. Well, Friday clinic overwhelms me. First of all, all of the orthopedic patients are told to come to clinic on Friday (remember, I am a general surgeon...bones are not my thing). In addition, most of the inguinal hernia patients are told to come to clinic on Friday and there always seem to be plenty of emergencies. It's can be a lot for one person to manage.

This Friday's clinic was no exception. I left conference early to get started. I spent the first 20 minutes trying to decipher charts to figure out who needed follow-up x-rays so I could send them all to radiology first thing. After sending about ten people to radiology, I started with a couple of inguinal hernia patients.

The first patient had had a successful left inguinal hernia repair here, then last year he went to have his right inguinal hernia fixed at another hospital. Only, he told me, they just "made an incision, looked, and closed without fixing it." Huh? I took a look. Yep, there was a nice incision and an obvious, reducible hernia. I don't know what they did at the other hospital. As usual, we don't have any records. But, he has a hernia and I know how to fix that.

After that, I continued on with the usual smattering of neck masses, mastitis,  non-specific abdominal pain, and spina bifida. After seeing about 10 non-orthopedic cases, I finally started in on the bones. X-rays, X-rays, X-rays. Keep the cast, take it off...not too bad. And then there was this: 

I wish..Proceed with caution: stop here if you don't want to see some slightly disturbing medical stuff.

A bent leg, an x-ray with a metal rod and a loose screw...its been three years since the operation and he is here for follow-up. I guess I should take the dressing off to see what's underneath.

As I unwrapped, suddenly some white things fell out of his ankle and onto the floor. White, wriggling things. Worms. Gross. Gross. Gross. Yep, his wound was full of worms...on the bright side it was otherwise pretty clean because they had been eating all the dead tissue. Once, while I was in training,  I put "sterile" maggots on a wound  to help with healing. Its not always a bad thing.

Fully unwrapped...exposed bone, exposed metal, and a pile of worms. Just when I think, "that's the worst... I've ever seen" I'm wrong again. He needs an amputation, but he refused to have the leg amputated.