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one view appears to show a step off or angulation but others do not, assume the worst.  If you are actually trying to find a gap or defect, i.e., “Is the heterotopic ossification actually Brooker grade IV (complete bridging), or is the screw outside the joint?” then the view that looks best is the one that speaks the truth.  

“Occult” femoral neck fractures: Femoral neck fractures are usually most visible on a 20o internally rotated AP view, which corrects the tilt of the anteverted femoral neck and throws it into complete profile.  If you are worried about an occult femoral neck fracture, it is worth getting this film before obtaining a bone scan.  When the patient has a femoral shaft fracture, you can’t internally rotate the femur and so must tilt the beam.

Dark films: If you are trying to see a dark film and do not have a bright light available, you can roll up another x-ray film into a small tube and look through the tube at the x-ray with your other eye closed.  The rolled up x-ray will exclude extraneous light, allowing your pupil to dilate and thus allowing visualization of even a dark film.  

WNL (we never looked): Don’t order preoperative chest x-rays on patients who don’t have an indication for them.  If you do order a preoperative chest x-ray, check the report.  If you miss a lesion and ignore the report, you will be found guilty.  

Forearm rotation: The bicipital tuberosity is on the same surface of the radius as the articular surface for the distal RU joint.  The ulnar styloid is on the dorsal/posterior surface of the ulna (opposite the shaft of the humerus).  These two facts can be very useful in assessing the rotation of the forearm bones radiographically.  

CT “edge effects”: Although they appear on the final printout as if they are infinitely thin slices through the body, CT slices do have a finite thickness.  This means that a structure that extends halfway across that finite thickness will appear to be half as dense as it actually is and may have an odd contour due to the obliquity with which the surface of the structure crosses the slice.  Being aware of this possibility can make it easier to interpret odd appearing structures that are merely artifacts of this edge effect.

Procedure Techniques

Outpatient/Emergency Room Procedures:

Failed blocks: Many “failed blocks” (hematoma blocks, nerve blocks, etc.) are due to surgeon impatience.  It can easily take 15 to 30 minutes for the block to reach its maximum effectiveness.  Do your paperwork while you’re waiting.  Another cause for failure is use of insufficient volume of anesthetic.  One study has shown that attempting to do hematoma blocks of the distal radius with less than 12 to 15 cc of 1% Lidocaine


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