Straight Leg Raise Cannot Replace Computed Tomography in the Detection of Spinal Column Fractures.

INTRODUCTION: An active straight leg raise (SLR) is a weight bearing test which assesses pain upon movement and a patient's ability to load their pelvis, lumbar, and thoracic spine. Since many stable patients undergo computed tomography (CT) scanning solely for spinal tenderness, our hypothesis is that performing active straight leg raising could effectively rule out lumbar and thoracic vertebral fractures. METHODS: Blunt trauma patients ≥18 years of age with Glasgow Coma Scale 15 presenting in hemodynamically stable condition were screened. Patients remaining in the supine position were asked to perform SLR at 12, 18, and 24 inches above the bed. The patient's ability to raise the leg, baseline pain, and pain at each level were assessed. Patients also underwent standard CT scanning of the chest, abdomen and pelvis. The clinical examination results were then matched post hoc with the official radiology reports. RESULTS: 99 patients were screened, 65 males and 34 females. Spinal fractures were present in 15/99 patients (16%). Mechanisms of injury included motor vehicle collision 51%, pedestrian struck 25%, fall1 9%, and other 4%. The median pain score of patients with and without significant spinal fractures at 12, 18, 24 inches was 7.5, 7, 6 and 5, 5, 4, respectively. At 24 inches, active SLR had sensitivity of 0.47, a specificity of 0.59, a positive predictive value of 0.17, and an negative predictive value of 0.86. CONCLUSIONS: Although SLR has been discussed as a useful adjunct to secondary survey and physical exam following blunt trauma, its positive and more importantly negative predictive value are insufficient to rule out spinal column fractures. Liberal indications for CT based upon mechanism and especially pain and tenderness are necessary to identify all thoraco-lumbar spine fractures.

Educational Quality of YouTube Videos for Patients Undergoing Elective Procedures.

INTRODUCTION: YouTube has become a main resource used by patients for self-education on medicine. It is important for surgeons to understand the quality and reliability of videos that patients are likely to view about elective procedures. METHODS: Videos were categorized by view count and content creators. The top 20 videos for each term, sorted by relevance, were evaluated using DISCERN criteria, a question set externally validated to assess the quality of information regarding health treatment choices. DISCERN score (DS) closer to 5 indicate higher quality information and 1 indicates the opposite. Total scores were given: 15-26 (very poor), 27-38 (poor), 39-50 (fair), 51-62 (very good), and 63-75 (excellent). Search terms included "Wound Care", "Skin Grafting", "Tracheostomy", and "percutaneous endoscopic gastrostomy tube placement". RESULTS: In total, 80 unique videos were evaluated with a total view of 8,848,796. The mean overall DS was 2.15 and a mean bias DS was 2.46. The median DISCERN total score for each key term was Tracheostomy: 35 (poor), Skin Grafting 26 (very poor), percutaneous endoscopic gastrostomy: 32 (poor), and Wound Care: 40 (fair). CONCLUSIONS: YouTube videos surrounding elective procedures should be viewed cautiously in patient education despite wide availability. The videos in this study show high levels of bias and low DS. Healthcare providers should be aware of poor-quality consumer health information often disseminated in online media such as YouTube.

Endoscopic Management of Ingested Narcotic Substances: A Case Report and Literature Review.

Management of swallowed narcotics remains in contention despite the increased frequency of occurrence. International societies recommend conservative therapy with escalation to surgical interventions in cases where drug packets do not progress. However, multiple studies demonstrate a treatment benefit of endoscopic intervention. We report the case of a 27-year-old male who presented after ingesting heroin bundles and failed the 48-hour of conservative therapy. Repeat computed tomography scanning demonstrated no movement of the package. Endoscopic retrieval was successful, and the patient was discharged the same day. Endoscopic intervention in the removal of bagged narcotics should be considered in patients presenting after purposely ingesting narcotics as means of planned concealment.

Renoduodenal Fistula Following Penetrating Abdominal Injury.

Renoduodenal fistula is an uncommon occurrence and usually results as a complication of injury or inflammatory process. Here, we describe a case of renoduodenal fistula formation after traumatic injury via gunshot wound to the abdomen. The patient suffered right renal and ureteral injury, complicated by urine leak, managed by surgery, interventional radiology, and urology. His post-hospital course was complicated by recurrent urinary tract infections and was found to have a renoduodenal fistula 3 months after the initial operation. Patient underwent uncomplicated right nephrectomy and repair of fistula. Etiology, presentation, diagnosis, and treatment options of renoduodenal fistula are discussed.

Head Computed Tomography Versus Maxillofacial Computed Tomography: An Evaluation of the Efficacy of Facial Imaging in the Detection of Facial Fractures.

Background: In an initial trauma evaluation, computed tomography of the head (CTH) is performed to assess for life-threatening intracranial injury. Given the high incidence of concomitant facial injuries, many facial fractures are diagnosed incidentally during this evaluation. Although maxillofacial CT (CTMF) is widely accepted as the most sensitive method for evaluating facial fractures, it is often excluded from the initial survey. Failure to obtain dedicated imaging can lead to increased costs related to a missed or delayed facial fracture diagnosis. Our study investigates the location and type of missed facial fractures on CTH by reviewing imaging data from patients who presented at a level 1 trauma center and underwent both CTH and CTMF. Methods: A retrospective review of all facial fractures diagnosed at a single institution from 2002 through 2016 was conducted. Inclusion criteria included adults aged 18 years or older who received CTH and then subsequent CTMF. Patients who had either CTH or CTMF only or combined CTH/CTMF were excluded. The facial fractures were further subdivided by location. Results: There were 501 patients with 1743 total facial fractures. CTH successfully identified 788 (45.21%) fractures, versus 1743 (100%) for CTMF. The most common fractures, in both cohorts, were nasal bone (15.7%) and orbital floor (12.8%) fractures. Using CTMF to identify missed fractures on CTH, significant differences were noted in the following locations: anterior table frontal sinus, medial/lateral pterygoid, maxillary sinus, lateral orbital wall, zygomatic arch, palate, and all types of mandible fractures excluding the mandibular condyle. Conclusions: CTH for initial trauma evaluation often misses facial fractures. CTH alone was only sufficient in detecting posterior frontal sinus, orbital (excluding lateral wall), and mandibular condyle fractures. In patients with suspected facial injury, dedicated imaging should be performed to detect the location and extent of injury because CTH inadequately identifies most facial fractures.