RADIOLOGY

Radiology updates

ANKLE JOINT DISLOCATION

Patient History

         H/o fall from hight RtAnkle

Examination  :- Patient unable to ambulant,with pain ,Bleeding,deformity on the Rt Ankle.open wound on the medial side of rt ankle about 10cm with exposeddistal tibia (G3A)

Radiological findings

       x-ray shows fracture dislocation at Rt ankle.

Operative steps:-

     medial ,incision extending same orfinal wound,tendon injury noticed.MM fixed with malleolor screw and K wire

LM..direct lateral incision noted at # LM

Fixed with DCP and screw

Findings:-

Rt ankle: crush wound irrigated, wound extended tibilis posterior tendone,FD tendone cut,crushedarea of tendone loss with contusion of posterial tibial nerve,

Tendones repaired using modified kissler and augmintation sutures approximated with difficulty due to area of tendone crush,loss

Medial malleolus # seen with bone loss reduced, fixed with 70mm mallelor screw amd K wire, (2), flexor retinaculam repaired and wound closed.

Fibula:-direct incision on lat malleoli severe communicated fracture lat malleoli was noted and reduction and fixation with planteand screw 7 hole small DCP with four screw proximal and 2 distal screw. Small fragment put in place with vicryl 1.wound closed b/k slab applied

Post Operative Diagnosis:

Type 3-a castillo & andreson bimaleolar # dislocation rt ankle with soft tissue crush injury.

Inter-vertebral Disc Prolapsed

How are the spine and its discs designed?

The vertebrae are the bony building blocks of the spine. Between each of the largest parts (bodies) of the vertebrae are the discs. Ligaments are situated around the spine and discs. The spine has seven vertebrae in the neck (cervical vertebrae), 12 vertebrae in the mid-back (thoracic vertebrae), and five vertebrae in the low back (lumbar vertebrae). In addition, in the mid-buttock, beneath the fifth lumbar vertebra, is the sacrum, followed by the tailbone (coccyx).

The bony spine is designed so that vertebrae "stacked" together can provide a movable support structure while also protecting the spinal cord (nervous tissue that extends down the spinal column from the brain) from injury. Each vertebra has a spinous process, which is a bony prominence behind the spinal cord that shields the cord's nerve tissue. The vertebrae also have a strong bony "body" in front of the spinal cord to provide a platform suitable for weight-bearing.

The discs are pads that serve as "cushions" between the vertebral bodies that serve to minimize the impact of movement on the spinal column. Each disc is designed like a jelly donut with a central softer component (nucleus pulposus). Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of the vertebrae and surround each of the discs. When ligaments are injured as the disc degenerates, localized pain in the area affected can result.

The Causes of Prolapsed Intervertebral Discs

Usually the intervertebral discs become less flexible with the aging, which increases the risk of injury. However, a prolapsed disc can also occur as a consequence of an injury such as falling, repeated straining, hard lifting, and also overweight.

What are symptoms of a herniated disc?

The symptoms of a herniated disc depend on the exact level of the spine where the disc herniation occurs and whether or not nerve tissue is being irritated. A disc herniation may not cause any symptoms. However, disc herniation can cause local pain at the level of the spine affected.

If the disc herniation is large enough, the disc tissue can press on the adjacent spinal nerves that exit the spine at the level of the disc herniation. This can cause shooting pain in the distribution of that nerve and usually occurs on one side of the body, referred to as sciaticas. For example, a disc herniation at the level between the fourth and fifth lumbar vertebrae of the low back can cause a shooting pain down the buttock into the back of the thigh and down the leg. Sometimes this is associated with numbness and tingling in the leg. The pain often is worsened upon standing and decreases with lying down.

If the disc herniation is extremely large, it can press on spinal nerves on both sides of the body. This can result in severe pain down one or both lower extremities. There can be marked weekness  of the lower extremities and even incontinence of bowel and bladder. This is medically referred to as ascaudaequina syndrome.

Location

The majority of spinal disc herniation cases occur in lumbar region (95% in L4-L5 or L5-S1).The second most common site is the cervical region (C5-C6, C6-C7). The thoracic region accounts for only 0.15% to 4.0% of cases.

Herniations usually occur posterolaterally, where the annulus fibrosis is relatively thin and is not reinforced by the posterior or anterior longitudinal ligament. In the cervical spinal cord, a symptomatic posterolateral herniation between two vertebrae will impinge on the nerve which exits the spinal canal between those two vertebrae on that side. So for example, a right posterolateral herniation of the disc between vertebrae C5 and C6 will impinge on the right C6 spinal nerve. The rest of the spinal cord, however, is oriented differently, so a symptomatic posterolateral herniation between two vertebrae will actually impinge on the nerve exiting at the next intervertebral foramen down. So for example, a herniation of the disc between the L5 and S1 vertebrae will impinge on the S1 spinal nerve, which exits between the S1 and S2 vertebrae.\

How is a herniated disc diagnosed?

The doctor will suspect a herniated disc when symptoms described above are present. The neurologic examination can reveal abnormal reflexes. Often pain can be elicited when the straight leg is raised when lying or sitting. This is referred to as a "positive straight leg raising test." There can be abnormal sensation in the foot or leg.

A variety of blood tests are frequently done to determine if there are signs of inflammation or infection.

Plain film X-rays can indicate "wear and tear" (degeneration) of the spine. They do not, however, demonstrate the status of discs. In order to determine whether or not a disc is herniated, an MRI Scan and CT Scan is performed for diagnosis.

An electrimylogram (EMG) can be used to document precisely which nerves are being irritated by a disc herniation.

How is a herniated disc treated?

Occasionally, disc herniation is incidentally detected when a test such as an MRI is performed for other reasons. If no symptoms are present, no particular treatment is necessary.

Depending on the severity of symptoms, treatments for a herniated disc include physical therapy, muscle relaxant medications, pain medications, anti-inflammation medications, local injection of cortisone (epidural injuction), and surgical operations. In any case, all people with a disc herniation should rest and avoid reinjuring the disc. Sometimes, even people with relatively severe pain early on can respond to conservative measures without the need for surgical intervention.

There are now a variety of surgical approaches to treat disc herniation. Each type of operation is customized to the individual situation and depends a great deal on the condition of the spine around the disc affected. Surgical options include microdiscectomy using small surgical instruments and open surgical repair (either from a posterior or anterior approach).

CASE - - FISH BONE

Case summary

A 35-year-old men attended the emergency department after swallowing a fish bone while eating dinner. he presented 2 hours after the incident and complained of feeling a foreign body stuck in his throat. A lateral neck radiograph was performed (Fig 1). He had made no attempts to remove thesupposedly retained fish bone nor did she vomit prior to the consultation. He had no other significantpain and was afebrile. The emergency department medical officer who examined his could not find a foreign body in her throat. There was no surgical emphysema. What is your diagnosis?

fig-1

fig-2

-  repeating the plain X-ray 3 hours later (Fig 2),

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