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Poland Syndrome- A Rare Congenital Disorder.

January 27, 2017, 9:36 am
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A 13 years old male came to radiology department for X-ray chest with history of cough for one month. His X- Ray is shown below:


Description: Chest X-ray  shows relative translucency of left hemithorax (or increased whiteness of right hemithorax) with mild scoliosis and pseudodextrocardia.

A CT scan was advised which is shown below:


Description: CT chest shows deficient muscle mass (pectoralis major muscle) in left hemithorax (white arrow) as the cause of abnormal X-ray chest and was diagnosed as Poland’s disease. The pectoralis muscle mass is normal on right side (black arrow).

Case Discussion:

Poland Syndrome: In Poland’s syndrome the etiology is not known and is described as an absence or hypoplasia of the pectoralis muscle on one side of the body with cutaneous syndactyly (webbing of the fingers) of the hand on the same side. Rib anomalies may also be associated.
It is a rare congenital condition.

The severity of Poland’s syndrome is variable and is often not diagnosed.
Poland’s syndrome is three times more common in males and affects the right side of the body twice as often as the left. The reasons for these differences are unknown, so is the cause.
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A Brief Description Of Burns

January 28, 2017, 9:42 am
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Definition: A burn is defined as any damage to the body's tissues caused by heat, chemicals, electricity, sunlight, or radiation. 
Scalds from hot liquids and steam, building fires and flammable liquids and gases are the most common causes of burns.
Burns are characterized by severe skin damage that causes the affected skin cells to die.

Types Of Burns: There are three types of burns:
  • First-degree burns damage only the outer layer of skin
  • Second-degree burns damage the outer layer and the layer underneath
  • Third-degree burns damage or destroy the deepest layer of skin and tissues underneath.
There is also a fourth-degree burns. This type of burn includes all of the symptoms of a third-degree burn and also extends beyond the skin into tendons and bones.

Clinical Features: Burns can cause swelling, blistering, scarring and, in serious cases, shock, and even death. They also can lead to infections because they damage your skin's protective barrier.
  • In first-degree burns: red, nonblistered skin
  • Second-degree burns: blisters and some thickening of the skin
  • Third-degree burns: widespread thickness with a white, leathery appearance
Immediate First Aid For Burns
  • Airway, breathing, circulation
  • Burns caused by heat: remove the person from the source. Within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes. Cover the burn using cling film, layered, rather than wrapped around a limb
  • Electrical burns: switch off power supply, remove the person from the source.
  • Chemical burns: brush any powder off then irrigate with water. Attempts to neutralize the chemical are not recommended.
Assessing The Extent of the Burn
Wallace's Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9%

Lund and Browder chart: the most accurate method the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA

Cases Which Need Referral to Secondary care
  • all deep dermal and fullthickness burns.
  • superficial dermal burns of more than 10% TBSA in adults, or more than 5% TBSA in children
  • superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck
  • any inhalation injury
  • any electrical or chemical burn injury
  • suspicion of nonaccidental injury

Management of Burns
  • initial first aid as above
  • review referral criteria to ensure can be managed in primary care
  • superficial epidermal: symptomatic relief analgesia, emollients etc
  • superficial dermal: cleanse wound, leave blister intact, nonadherent dressing,
  • avoid topical creams, 
  • review in 24 hours
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SARS- Severe Acute Respiratory Syndrome -- Charts

January 28, 2017, 9:53 am
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X ray Chest Showing Fracture Of The Left Clavicle.

January 28, 2017, 10:04 am
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A 56 years old female came to radiology department for X-ray chest with history of hypertension and pain in chest. She had a history of fall few days back but came to medical attention today.

Her X ray is shown below:


Description: X-ray chest shows normal lung fields. The examination of the film is not complete until the bones and soft tissues have also been surveyed. There is a fracture through the mid diaphysis of left clavicle with overlap of the bony fragments.

Clinical Discussion: Once the fractures of the clavicle is seen on X-ray chest,
it is important to look for any associated injury to the subclavian vessel or brachial plexus, and posterior dislocation of the clavicle at the sternoclavicular joint may cause injury to the trachea, esophagus, great vessels or nerves of the superior mediastinum.

In this particular case it is important to rule out domestic abuse and reasons for delay in medical care.

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A 38-year-old man presents with rapid hair loss that has occurred over the last few weeks.

January 28, 2017, 10:12 am
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A 38-year-old man presents with rapid hair loss that has occurred over the last few weeks. He reports that his father had a similar condition.
The picture is shown below:



The most likely diagnosis is
A) Alopecia areata
B) Androgenic alopecia
C) Tinea capitis
D) Trichotillomania
E) Secondary syphilis

The answer is
A. (Alopecia areata)

Discussion: Alopecia areata is associated with sudden hair loss that occurs in round patches. The patches are well circumscribed and are not associated with scarring or inflammation. Patients
have no other symptoms. The most common area affected is the scalp; however, the condition may also affect the eyebrows or beard. Alopecia areata usually affects children and young adults and is recurrent. A pathognomonic sign for alopecia areata is the “exclamation point” hair, which is wide distally and narrower at the base. These hairs are often found at the periphery of a patch of hair loss. Hair that regrows in the area of alopecia areata is in many cases white. Nail pitting may also be present.
The treatment consists of injection of intralesional steroids and topical steroids. Most experience complete regrowth of hair.

The following related article may be useful.

http://studymedicalphotos.blogspot.com/2015/05/a-32-year-old-man-presents-with-hair.html
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Basilar Skull Fracture

January 28, 2017, 2:00 pm
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Introduction: The skull “base” comprises the frontal bone, occiput, occipital condyles, clivus, carotid canals, petrous portion of the temporal bones, and the posterior sphenoid wall. A basilar skull fracture is basically a linear fracture of the skull base.

Clinical Features: Trauma resulting in fractures to this area typically does not have localizing symptoms.
Indirect signs of the injury may include visible evidence of bleeding from the fracture into surrounding soft tissue, such as a Battle sign or “raccoon eyes.” (see picture shown below)

Battle Sign. A striking Battle sign is seen in this patient with head trauma. This finding may take hours to days to develop.


Bleeding into other structures—including hemotympanum or blood in the sphenoid sinus seen as an air-fluid level on computed tomography (CT)—may also be seen. Cerebrospinal fluid (CSF) leaks may also be evident and noted as clear or pink rhinorrhea. If CSF is present, a dextrose stick test may be positive. The fluid can be placed on filter paper and a “halo” or double ring may be seen.


Raccoon Eyes. Acute periorbital ecchymosis seen in this patient with a basilar skull fracture. These findings may also be caused by facial fractures.

Management 
1. Identify underlying brain injury, which is best accomplished by CT. CT is also the best diagnostic tool for identifying the fracture site, but fractures may not always be evident.
2, Evidence of open communication, such as a CSF leak, mandates neurosurgical consultation and admission. Otherwise, the decision for admission is based on the patient’s clinical condition,
other associated injuries, and evidence of underlying brain injury as seen on CT.
3. The use of antibiotics in the presence of a CSF leak is controversial because of the possibility of
selecting resistant organisms.

Important Points To Remember: 

  • Clinical manifestations of basilar skull fracture may take several hours to fully develop.
  • There should be a low threshold for head CT in any patient with head trauma, loss of consciousness, change in mental status, severe headache, visual changes, or nausea or vomiting.
  • The use of filter paper or a dextrose stick test to determine if CSF is present in rhinorrhea is not 100% reliable.

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A Lipoma On The Chest Wall

January 29, 2017, 1:55 pm
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A 54 years old male presents with a history of a large painless chest wall swelling on right side, which is there for the last seven years and has gradually increased in size. It was soft in consistency and non-adherent to the underlying ribs.

                                                 the swelling as seen from the back. 

An X ray chest was done which is shown below:


Chest X-ray shows a homogeneous soft tissue mass lesion without any calcification arising from the right lateral chest wall. The underlying ribs are normal; they show no erosion or pressure effect.

Diagnosis: History, clinical finding and X-ray chest are suggestive of lipoma.

Discussion: Ideally, CT is important as it provides a definitive diagnosis of lipoma but the patient
failed to report back after chest X-ray. Most chest wall lipomas that originate are superficial, in this case arising from right posterolateral chest wall
 On CT and MRI lipomas appear homogeneous and show no contrast enhancement, it may have multiple thin septa which may enhance on contrast CT and have low signal intensity on fat-suppressed T1-weighted MR images. Spindle cell lipoma is a rare, painless, and slow-growing
neoplasm in which mature fat cells are replaced by collagen-forming spindle cells.

Lipomas are well-defined encapsulated mass lesions made up of adipocytes very similar to normal fatty tissue generally seen between 50–70 years of age. Lipomas that originate in the chest wall may be superficial or deep extending into the chest.
In chest, lipoma may be seen in the mediastinum though very uncommon. Then there are cardiac lipomas, they are the second most common benign cardiac tumors, their origin can either be epicardial, endomyocardial or subendocardial in location, most common in relation to left ventricle and right atrium.
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Neonatal Conjunctivitis - A Brief Discussion

January 29, 2017, 2:17 pm
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Neonatal conjunctivitis is acquired either during birth with passage through the mother’s cervix and vagina, or from cross-infection in the neonatal period.

Etiologies: More common etiologies include Chlamydia trachomatis, viruses (herpes simplex), and bacteria (Staphylococcus aureus, Streptococcal pneumoniae, Haemophilus species).

Clinical Features: 

  • Presenting symptoms for Neisseria gonorrhoeae infection include a hyperacute bilateral conjunctivitis with copious purulent discharge, lid swelling, chemosis, and preauricular adenopathy.

            Thick purulent drainage in a newborn diagnosed with neonatal gonococcal conjunctivitis.

  • For chlamydial conjunctivitis, the clinical features range from mild swelling with a watery discharge to marked lid swelling with a red and thickened conjunctiva with a blood-stained discharge. 
  • Fluorescein staining of herpes simplex conjunctivitis demonstrates epithelial dendrites.
  • Blindness can result from gonococcal eye infection in the neonate because the organism can invade the cornea. It is one of the few emergency conjunctival infections.
  •  Nasolacrimal duct obstruction is common (up to 20%) in newborns and may present with findings suggestive of conjunctivitis. It is a diagnosis of exclusion in the neonate.

            A scant crusty discharge is seen in this newborn who was diagnosed in follow-up with                         nasolacrimal duct obstruction



Diagnosis: With any form of neonatal conjunctivitis, Gram stain and culture are indicated. Scrapings of the palpebral conjunctiva are more likely to be rewarding than examination of the discharge

itself. 

The “rule of fives” may help predict the most likely bacterial cause.
0-5 days.......................Gonococcus
5 days-5 weeks............Chlamydia
5 weeks-5 years..........Staphylococcus, Streptococcus, Haemophilus

Treatment: Begin treatment in the emergency department (ED) and admit newborns with suspected gonococcal conjunctivitis.
Evaluate concurrently for C trachomatis, since coinfection is common.

Treatment for chlamydial conjunctivitis is based upon a positive diagnostic test. While culture is the gold standard, nucleic acid amplification tests, despite lacking FDA approval, are reported to perform similarly. 

Untreated disease can result in corneal and conjunctival scarring. 
  • Bacterial neonatal conjunctivitis that is neither gonococcal nor chlamydial may be treated with erythromycin antibiotic ointment and should be reevaluated in 24 hours.
  • Herpes simplex conjunctivitis is treated with intravenous (IV) acyclovir and topical trifluridine. Despite the appearance of a localized herpes infection, there is high risk for central nervous system (CNS) or disseminated infection.
Evaluation of the newborn’s parents should be undertaken in neonatal conjunctivitis due to Gonococcus, Chlamydia, or herpes simplex virus (HSV).

1. Chemical Neonatal Conjunctivitis: Seen on day 1. and is common with use of silver nitrate for prophylaxisis. (erythromycin more commonly used now for this reason). It is self limited and needs no treatment. 

2. N gonorrhoeae Conjunctivitis: Appears between day 2-7, and may cause hyperacute disease with profuse discharge. Treatment is with Ceftriaxone IV. (Caution in hyperbilirubinemia.) Topicals treatment alone is inadequate.

3. C trachomatis Conjunctivitis: Appears between day 3-14. Clinical severity varies and it is a common cause of blindness worldwide. Treatment with Erythromycin. 

4. HSV 1,2: Appears anytime between day 2 &16 and should be suspected if child has any vesicular lesions on body. Treatment is with Vidarabine or trifluridine topically; consider systemic acyclovir.

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Management Of Pressure Ulcers

January 30, 2017, 1:25 pm
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A 85-year-old debilitated nursing home resident was found to have pressure ulcers. He has no evidence of bacteremia or osteomyelitis. Which of the following is an acceptable treatment?
A) Application of povidone-iodine gauze two times per day
B) Application of hydrogen peroxide 3 times per day
C) Systemic antibiotics for 7 to 10 days
D) Keeping the area clean and dry until granulation tissue forms
E) Surgical debridement

The answer is
E. (Surgical debridement)

Discussion: When treating pressure ulcers, it is important to maintain a moist environment while keeping the surrounding skin dry. This can be accomplished by loosely packing the ulcer with saline-moistened gauze. Topical antimicrobials such as silver sulfadiazine cream may be helpful in ulcers that appear infected. Topical antiseptics such as povidone-iodine or hydrogen peroxide should not be
used in the treatment of pressure ulcers. Systemic antibiotics should be reserved for serious infections (e.g., bacteremia, osteomyelitis). A 2-week trial of topical antimicrobials may be considered for ulcers that do not appear infected but are not improving. Although most patients are successfully managed without surgery, procedures may be appropriate in patients whose quality of life would be markedly improved by rapid wound closure. Stage 3 and 4 ulcers with necrotic tissue should be debrided. Ulcers with minimal exudate that are not infected can be covered with an occlusive dressing to promote autolytic debridement. Ulcers with thick exudate, slough, or loose necrotic tissue should undergo mechanical debridement. Options include wet-to-dry dressings, hydrotherapy, wound
irrigation, and scrubbing the wound with gauze. Ulcers with evidence of cellulitis or deep infection should undergo sharp debridement with a scalpel or scissors. Ulcers with a thick eschar or extensive necrotic tissue should undergo sharp debridement as well. However, a thick, dry eschar covering a
heel ulcer should generally be left intact. Patients without access to surgical interventions (such as in a long-term care setting) or those who may not be acceptable surgery candidates can be treated with enzymatic debriding agents. Wound debridement should stop once necrotic tissue has been
removed and granulation tissue is present.
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Normal Fundoscopic Examination

January 30, 2017, 1:34 pm
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Normal Fundus. The disk has sharp margins and is normal in color, with a small central cup. Arterioles and venules have normal color, sheen, and course. Background is in normal color. The macula is enclosed by arching temporal vessels. The fovea is located by a central pit.

Introduction. Fundoscopic examination should be a part of routine physical examination and it is important to know the normal findings in order to detect the abnormalities. Here a brief discussion is given about normal finding on fundoscopic examination.

Disk: The disk is pale pink, approximately 1.5 mm in diameter, with sharp, flat margins. The physiologic cup is located within the disk and usually measures less than six-tenths the disk diameter. The cups should be approximately equal in both eyes.

Vessels:The central retinal artery and central retinal vein travel within the optic nerve, branching near the surface into the inferior and superior branches of arterioles and venules, respectively. Normally the walls of the vessels are not visible; the column of blood within the walls is visualized. The venules are seen as branching, dark red lines. The arterioles are seen as bright red branching lines, approximately two-thirds or three-fourths the diameter of the venules.


Macula: This is an area of the retina located temporal to the disk; it is void of visible vessels. The fovea is an area of depression approximately 1.5 mm in diameter (similar to the optic disk) in the center of the macula. The foveola is a tiny pit located in the center of the fovea. These areas correspond to central vision.

Background : The background fundus is red; there is some variation in the color, depending on the amount of individual pigmentation and the visibility of the choroidal vessels beneath the retina.

Points To Remember: 

  • The cup/disk ratio is slightly larger in the African American population.
  • The normal fundus should be void of any hemorrhages, exudates, or tortuous vasculature.


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Radiological Findings In Multiple Myeloma

January 30, 2017, 1:46 pm
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An 87 years old male came to radiology department for X-ray chest with history of bone pains, lethargy and cough.


The above X ray shows generalized reduction in bone density with wide spread destructive foci. The lesions are more prominent and larger in size in the left clavicle and proximal part of humerus. In
view of destructive bone lesions, patient was subjected to X-ray skull.


Chest X-ray shows prominent and large size destructive foci in the left clavicle and proximal part of humerus (arrows). X-ray skull (inset) shows multiple wide spread osteolytic rounded circular
defects of varying diameter from 2 mm to 15 mm with no surrounding bone reaction or sclerosis. The disseminated or generalized form of plasma cell infiltration of bone marrow is known as multiple myelomatosis. It is much more common for the widespread form to present radiologically as a fully developed entity over 40 years of age. 
Men are affected twice as common as women. Persistent bone pain or a pathological fracture is usually the first complaint.

Clinical Discussion: The two cardinal features in multiple myeloma are generalized reduction in bone
density and localize areas of radiolucency in red marrow areas. The axial skeleton, therefore, is affected predominantly. Lesions may be observed also in the shafts of long bones and in the skull. In spite of positive bone marrows aspiration, radiological feature may be absent in as many as one third of cases, at least at the initial presentation. This group of patients tends to develop generalized osteoporosis. Fifty percent cases present with proteinuria (Bence Jones proteinuria).

Radiology plays an important part in the initial diagnosis of the disease. A radiographic skeletal survey is superior to scintigraphic investigation using a bone-scanning agent, because the lesions are essentially osteolytic with no bone reaction. The distribution of lesions is extensive and destructive. The disease will not always be evident by the presence of the classic ‘raindrop’ lesions, circular defects of few mm to 2 or 3 cm in diameter.
Myelomatous lesions may erode the cortex and extend into the adjacent soft tissues. The resulting soft tissue masses are helpful in differentiating the advanced form of the disease from metastatic lesions. In chest, a destructive rib lesion with a large associated soft tissue mass is much more suggestive of myelomatosis than of a plasmacytoma
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Tooth Subluxation

January 31, 2017, 8:23 am
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A 27 year old male was seen in the emergency department following a trauma and bleeding from the mouth. On examination he was found to have teeth subluxation due to the trauma.

Tooth Subluxation. Note the presence of blood along the crevice of the gingival margin of both central incisors—an indication of subluxation following trauma. Mild displacement of the subluxated teeth is noted


Case Discussion: 
Tooth subluxation, the loosening of a tooth in its alveolar socket, is most commonly secondary to trauma; however, infection and periodontal disease may also produce subluxation.
Gingival lacerations and alveolar fractures are associated with dental subluxations. Gentle pressure to the teeth with a tongue blade or fingertip may produce movement, mild displacement, or blood along the crevice of the gingiva, all signs of subluxation.

Dental impaction and alveolar ridge fracture should be considered and ruled out clinically or radiographically.

Management: 
1. Primary teeth: If the subluxated tooth is forced into close proximity to the underlying permanent tooth, follow-up for extraction is indicated. Otherwise, the patient should be instructed to follow a soft diet for 1 to 2 weeks, allowing the tooth to reimplant spontaneously.
2. Permanent teeth: Unstable teeth should be temporarily immobilized using gauze packing, a figure-eight suture around the tooth and an adjacent tooth, aluminum foil, or a special periodontal dressing, and the patient referred for dental follow-up.

Important Learning Points: 
1. Any evidence of tooth mobility following trauma is a subluxation by definition.
2. Always consider an associated underlying alveolar or occult root fracture.
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Understanding Axis Deviation On ECG

February 1, 2017, 7:50 am
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Traumatic Asphyxia - Brief Discussion

February 1, 2017, 8:08 am
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Traumatic Asphyxia:  Traumatic asphyxia, also known as  Perthe's syndrome, is a medical emergency caused by an intense compression of the thoracic cavity, causing venous back-flow from the right side of the heart into the veins of the neck and the brain

The clinical findings of traumatic asphyxia are due to a sudden increase in intrathoracic pressure against a closed glottis. The elevated pressure is transmitted to the veins, venules, and capillaries of the head, neck, extremities, and upper torso, resulting in capillary rupture.

Strangulation and hanging are common mechanisms. Survivors demonstrate plethora, ecchymoses, petechiae, and subconjunctival and retinal hemorrhages.

Body showing  dark purple Tardieu spots in dependent areas, due to ruptured capillaries in a person who suffered from Traumatic Asphayxia
Severe injuries may produce central nervous system injury with blindness, seizures, posturing, and paraplegia and even death.

Management: Treatment is supportive, with attention to other concurrent injuries. Long-term
morbidity is related to the associated injuries.

Most cases are seen on postmortem examination.


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Testicular Torsion

February 1, 2017, 8:26 am
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 A young male , age 16 years presents to the emergency with the complain of the sudden onset of pain in one testicle, followed by swelling of the affected testicle, reddening of the overlying scrotal skin, lower abdominal pain, nausea, and vomiting.
An examination reveals a swollen, tender, retracted testicle that often lies in the horizontal plane (bell-clapper deformity).

A diagnosis of Testicular torsion was made and the patient was prepared for immediate surgery.

Case Discussion:



Testicular torsion is one of the urologic emergencies and is very painful on presentation.

Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. The reduced blood flow causes sudden and often severe pain and swelling.

Testicular torsion is most common between ages 12 and 16, but it can occur at any age, even before birth.


Testicular torsion usually requires emergency surgery. If treated quickly, the testicle can usually be saved. But when blood flow has been cut off for too long, a testicle might become so badly damaged that it has to be removed.

Etiology: The most common underlying cause is a congenital malformation known as a "bell-clapper deformity" wherein the testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels.

Clinical Features: Signs and symptoms of testicular torsion include:
  • Sudden, severe pain in the scrotum
  • Swelling of the scrotum
  • Abdominal pain
  • Nausea and vomiting
  • A testicle that's positioned higher than normal or at an unusual angle
  • Painful urination
  • Fever
Young boys who have testicular torsion typically wake up due to scrotal pain in the middle of the night or in the morning.
The spermatic cord is frequently swollen on the affected side. In delayed presentations, the entire hemiscrotum may be swollen, tender, and firm.

Diagnosis: The diagnosis should usually be made on the presenting signs and symptoms and an urgent ultrasound should only be done when the diagnosis is unclear. 
The urine is usually clear with a normal urinalysis. In one-third of cases, there is a peripheral leukocytosis.
Irreversible ischemia begins around six hours after onset and emergency diagnosis and treatment is required within this time to minimize the risk of testicle loss.

Treatment: With prompt diagnosis and treatment the testicle can often be saved. Typically, when a torsion takes place, the surface of the testicle has rotated towards the midline of the body. 
Non-surgical correction can sometimes be accomplished by manually rotating the testicle in the opposite direction (i.e., outward, towards the thigh); if this is initially unsuccessful, a forced manual rotation in the other direction may correct the problem. The success rate of manual detorsion is not known with confidence.

Testicular torsion is a surgical emergency that requires immediate intervention to restore the flow of blood. If treated either manually or surgically within six hours, there is a high chance (approx. 90%) of saving the testicle.

Common treatment for children is surgically sewing the testicle to the scrotum to prevent future recurrence (orchiopexy).

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Acromioclavicular Joint Seperation

February 1, 2017, 8:39 am
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Injury to the acromioclavicular (AC) joint usually results from an impact on the superior aspect of the acromion.

The classification system for AC joint injuries includes six types.

  • A type I injury is equivalent to a stretching of the AC ligament. 
  • A type II injury consists of tearing of the AC ligaments and stretching of the coracoclavicular ligaments. 
  • Complete disruption of the AC and coracoclavicular ligaments is seen in types III to VI.



Clinical Features: Patients complain of pain at the AC joint and will actively splint the injured shoulder. Ecchymosis may be present; however, an obvious deformity is not always seen. There is significant tenderness upon palpation of the AC joint.

Diagnosis: Standard radiographs should include anteroposterior (AP) and axillary lateral views of the shoulder.


  • Type I injuries will appear normal. 
  • Type II injuries may show 0% to 50% displacement at the AC joint but no increase in the coracoclavicular interval. 
  • Types III to VI will demonstrate displacement at the AC joint and the clavicle will appear to be displaced superiorly (the acromion actually is rotated inferiorly) 50% to greater than 100% its width when compared with the normal side.
    AC Joint Separation, Third Degree. A wide AC joint and the clavicle displaced from the acromion.

Management: 
  • Type I and type II injuries are treated with rest, ice, analgesics, and a simple sling until acute pain with movement is relieved. 
  • Treatment of type III injuries may be nonoperative or operative. However, these patients can be discharged from the emergency department in a sling without an emergent orthopedic consult. 
  • Types IV, V, and VI are treated operatively.
  • Referral to a musculoskeletal specialist is essential for all AC joint injuries since many patients who initially appear to have minor injuries will have more obvious deformity after the swelling and pain have subsided.
Points To Remember: 

1. The early AC joint stress radiograph can be negative due to splinting of the shoulder girdle muscles and does not add anything to the acute patient management.
2. Differentiating between types I and II versus types IV to VI is the goal of the ED physician, since the latter will require an emergency orthopedic consult.
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A 3 Year Old Child With A Mass On The Chest

February 1, 2017, 8:46 am
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A 3 years old child was seen by the pediatrician for a large soft tissue mass on right side of chest.

Photograph (A) of the child shows the soft mass (arrow), on X-ray chest (B) the soft tissue lymph nodal mass lies outside the thoracic cage in right hemithorax.

Diagnosis: Lymph node mass.

Discussion: On X-ray chest the lung fields are clear, on X-ray chest it is important to look for any lesion in the soft tissue over the entire available film. It may be in the form of enlarged thyroid gland, cervical or axillary lymph nodes, neurofibroma, surgical emphysema, a lesion in the breast or one
of the breasts might have been surgically excised. Ultrasound can be useful in investigating nodal masses particularly as an aid to biopsy.


CT is generally the method of choice, providing a direct and reproducible demonstration of normal and abnormal lymph nodes. MRI has potential to replace CT in the assessment of nodal disease, although at higher cost, MRI is the option during follow-up of nodal disease being radiation free.

Lymph node enlargement is the hallmark of metastatic disease keeping in mind the size criteria for normal and abnormal lymph nodes have evolved in the different areas of the body.
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A 19 Year Old Male With Cough, headache and Malaise...

February 1, 2017, 9:02 am
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A 19-yr -old army cadet is admitted to hospital with cough, headaches and malaise. He has a temperature of 38°C. His blood count and renal and liver function are normal. Cold agglutinins
are positive. A CXR shows bibasal shadowing.



What is the most likely Dx?

A. Legionella pneumonia
B. Viral pneumonia
C. Q fever
D. Klebsiella pneumonia
E. Mycoplasma pneumonia

Answer:
E) Mycoplasma pneumonia

Discussion: Mycoplasma pneumonia is a common cause of pneumonia, often occurring in young people. It is characterised by headaches, malaise and cough. The CXR findings might not correlate with the pt’s condition. The WCC can be normal and cold agglutinins occur in only half of pts.
Extrapulmonary complications include: Pericarditis, Myocarditis, Erythema multiforme, Vomiting, Diarrhoea and Meningo-encephalitis
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Cellulitis - A Brief Discussion

February 2, 2017, 1:06 pm
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Cellulitis is a common infection of the skin or subcutaneous tissues with characteristic findings of:
  • erythema with poorly defined borders, 
  • edema, warmth, pain, and limitation of movement.
  • Fever and constitutional symptoms may be present and are commonly associated withm bacteremia. 
     Cellulitis of the right lower extremity characterized by sharply demarcated erythema an edema.



Predisposing factors include:


  • trauma, 
  • lymphatic or venous stasis, 
  • immunodeficiency (including diabetes mellitus), and 
  • foreign bodies.

Common etiologic organisms include:

  • group A β-hemolytic Streptococcus 
  • Staphylococcus aureus in nonintertriginous skin, and  gram-negative organisms or mixed flora in intertriginous skin and ulcerations. 
  • In immunocompromised hosts, Escherichia coli, Klebsiella species, Enterobacter species, and Pseudomonas aeruginosa are common. 
  • In recent years, there has been a dramatic increase in the incidence of community- acquire methicillin-resistant S aureus (CA-MRSA), particularly in cellulitis associate with a cutaneous abscess.

The differential diagnosis includes 
  • Deep venous thrombosis (DVT), 
  • Venous stasis, 
  • Erythema nodosum, 
  • Septic or inflammatory arthritis/bursitis, and 
  • Allergic reactions.
Treatment of minor cases commonly consists of :
  • immobilization,
  • elevation, 
  • analgesia, and
  • oral β-lactam antibiotics with reevaluation in 48 hours. 
The increase in the incidence of CA-MRSA has prompted some, especially in highly endemic
areas, to advocate coverage with trimethoprim/sulfamethoxazole or other agents
  • Admission and parenteral administration of antibiotics may be necessary for immunocompromised or toxic-appearing patients, or those who do not respond to outpatient therapy.
Points To Remember: 
1. Rapidly progressive cellulitis or one that progresses despite treatment with β-lactam antibiotics should raise suspicion for CA-MRSA or deeper infections such as fasciitis.
2. Known risk factors for CA-MRSA include military personnel, prison inmates, and competitive sports players.
3. Routine blood or leading-edge cultures in nontoxic patients are generally low yield .

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Cherry Hemangiomas (Campbell De Morgan spots Or Senile Angiomas)

February 2, 2017, 1:35 pm
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Cherry hemangiomas also known as Campbell De Morgan spots or senile angiomas are the most common cutaneous vascular proliferations. They are often widespread and appear as tiny cherry-red papules or macules. Longstanding lesions enlarge slowly over time and take on the appearance of a dome topped with cherry-red to deep-purple papules.

They are more common with advancing age and affect men and women equally.

Clinical Features
  • erythematous, papular lesions
  • typically 1-3 mm in size
  • nonblanching
  • not found on the mucous membranes
Causes: The exact cause of cherry angiomas is unknown, but there may be a genetic factor that makes certain people more likely to get them. They’ve also been linked to pregnancy, exposure to chemicals, and climate.
There also appears to be a link between cherry angiomas and age. They often begin to appear when individuals reach 30 years old, and seem to increase in size and number with age.

Management:
Medical intervention is not helpful and not indicated in the treatment of the benign vascular proliferations of cherry hemangiomas. Perform biopsy on lesions in which the diagnosis is doubtful. The biopsy procedure may be used as a therapeutic measure to remove traumatized or bleeding lesions.

Surgical treatment is recommended only in situations of irritation or hemorrhage or in instances in which the lesions are deemed by the patient to be cosmetically undesirable.

The options include: 
  • Electrocauterization
  • Cryosurgery
  • Laser surgery
  • Shave excision
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