The end or just the begining?......

Well, it's the end of my PBM & the three weeks have passed very quickly. Despite the fact that NOF patients were few and far between (than usual) I feel as though I have achieved what I set out to do. I think I've experienced/seen enough of the NOF 'patient journey', from initial admission to post surgery, to achieve my objectives and put together my poster. I've also enjoyed working with & learning from the radiographers and I'm grateful for their help/assistance.


As I have commented before, the three weeks in A&E have increased my confidence in adapted techniques, selection of exposure factors & image analysis when undertaking various trauma examinations. The whole experience has highlighted how much I've learnt but more importantly how much I still need to learn, develop & improve during the final year & post qualification to become a skilled radiographer. I think the experience has shown me how I now need to challenge myself more during my final year & start thinking about the transition from a student to a qualified radiographer. So therein lies the answer... it's not the end but the beginning.......Aum

Almost the end...

Tuesday

Worked the evening shift (12pm to 8pm) to see if I would see any more NOF trauma cases. However, despite the A&E being very busy there was not one to be seen!. However, I did manage to get additional 'hands on' experience of imaging facial bones & C-spine trauma. I also managed to go to theatre & get to talk to the theatre staff about patient management and various prosthesis used. I think I managed to get some very good info for the poster.


Wednesday

Today there were 2 NOF cases which the radiographers left for my fellow student & I to image. Between us we managed to get excellent diagnostic images, i.e. AP pelvis & horizontal beam lateral. It did wonders for our confidence when the radiographer overseeing the examination commented about our good technique/positioning. Things can only get better........

Protocols & Techniques

On Thursday morning I managed to image two NOF 's and thought it might be informative for you eager readers to know what actually happens. Here goes...

For trauma to the neck of femur department protocol at my PBM hospital is that first an anteroposterior (AP) of the pelvis is undertaken (see image below). The image should include the whole of the pelvis (including both hip joints), upper third of each femur and soft tissue outlines. All neck of femur trauma should be carried out on the trolley that the patient arrives on and if the injured limb is externally rotated it must not be moved.

When looking at the image the radiographer compares the injured side with the uninjured side. He/she assesses for normal trabecular pattern and that the cortex is intact. The pubic rami is also carefully assessed as if it is fractured it can mimic the sign and symptoms of a femoral neck fracture.

If a fracture is suspected then the department protocol states that a horizontal beam lateral of the affected hip should be undertaken. It also states that a pre-operative chest x-ray is undertaken at the same time if the patient is over 70 years old. The chest x-ray is to assess the patients health prior to operating.

Horizontal Beam lateral

When a fracture is suspected a second view must be achieved. With a trauma patient the affected leg cannot be moved so a horizontal beam lateral is performed. So what's involved? The standard procedure at this hospital (in A&E) is to use an air gap technique using the erect automatic exposure grid (AED). The patient is supine on the trolley with the affected limb extended (see diagram below). The trolley is positioned so that the median saggital plane (MSP) is 45 degrees to the cassette in the erect bucky. This brings the the neck of femur parallel to the cassette. The unaffected limb is raised onto a support so that it is not in the way of the primary beam. Apparently, the air gap between the patient and the cassette reduces radiation scatter to the resulting image and also helps reduce the radiation dose to the patient. To compensate magnification of the object to film distance, the distance between the cassette & the tube is increased to 180 cm. The standard exposure used is 105 kVp with some radiographers adjusting the mAs to -1 or -2. If manual settings are used then the average exposure setting is 90 kVp & 120 mAs. The horizontal ray is centered through the crease of groin to the middle of the cassette, midway between the anterior and posterior soft tissue of the thigh. A filter is used to optimise overall image density. One particularly important thing to note is that positioning for a horizontal lateral hip can be challenging as most patients are old & infirm and that they should be treated in a respectful & compassionate manner. For instance, the patient I x-rayed on Thursday was an elderly female who commented how 'undignified' she felt when her unaffected leg was raised onto the support. As such it's important to remember the patients’ dignity when undertaking this image, especially if the patient is of the opposite sex.

The resulting image (see below) should include upper 2/3rd of NOF with a clear view of acetabulm.
So there you have it, an overview of what the protocols are at my PBM hospital & what's involved.

NOF at last!

Monday was a very busy day in A&E, as expected, but alas not a single NOF was to be seen! However, I worked with some excellent Radiographers who shared their skill & knowledge when I was carrying out numerous adapted techniques for various requests. The nuggets of info is helping me achieve good technique in both patient positioning & exposure settings. This has really helped my confidence in tackling more challenging requests. For instance, today there was a trauma patient, on a trolley, who was involved in a road traffic accident (RTA) who needed x-rays of the C, T & L spine!. Well, myself & my fellow student (also doing her PBM on NOF) picked up the request card, OK'd it with a radiographer and went ahead and carried out the examination. Although we weren't 100% confident we thought that we would carry out the imaging since sometimes being thrown in at the deep end is the only way to learn!. Despite having a couple of radiographers & a nurse watching us we took our time & between us carried out an AP C1/C2 (peg) view, Swimmers view, AP & HB lateral C, T & L-spine! The images were all of very good diagnostic quality & the radiographer overseeing the examination commented that any spine trauma requests this week will be passed on to both of us! During my second year of clinical placement I would have avoided such a situation but now I honestly feel very comfortable taking on any requests and asking for help from the radiographers when I need to.


Oh yes, as my fellow student & I were getting ready to finish for the day today 2 NOF's arrived at 4.50pm! We decided to stay behind & help carry out the imaging. The patient I x-rayed had a sub-capital fracture which is exactly what I needed for my PBM. As such I intend to try & follow up on this patient's journey this week, i.e. go to the orthopedic ward, theatre, etc.

End of first week!

After a good start on Monday I only got to image one NOF all week! I intend to work a couple of evening shifts next week to increase my chances of seeing & being involved with imaging some more NOF’s. The week was not a total loss as I managed to get some very good experience of adapted techniques for a variety of requests which has enabled me to challenge myself & increased my confidence in A&E. On Thursday I spent the day in A&E Minors and Majors shadowing, talking and pestering doctors and nurses to enable me to complete my first objective for the PBM. At times it was like pulling teeth but I managed to get some good info which has helped link the theory to actual clinical practice. I’ve just put together the following notes (very brief!) so that it may help all you eager readers gain an introductory overview of the area of interest for my PBM .

The basics – NOF Anatomy
The hip joint is a ball-and-socket joint between the femur and the pelvis (See diagram below). The upper (rounded) end of the femur is called the head, which is connected to the shaft of the femur by the neck. At the base of the neck are two bony lumps, the Greater Trochanter and Lesser Trochanter (for muscle attachments) The socket component of the joint known as the acetabulum which surrounds about 2/3rd the head of the femur.

Trauma to the hip
The most common cause is usually a minor stumble or fall in an elderly patient, although it is possible to fracture a femoral neck as part of more serious multiple trauma. The hip joint is similar to the shoulder joint, although not as mobile. However, it can withstand much greater stresses than the shoulder and is more stable and it takes a lot of force to dislocate it. Hence the neck is more likely to break than the joint is to dislocate, especially in elderly patients where the bones are weakened through degenerative changes such as osteoporosis. Another interesting fact I was told is that it is possible to cut all the ligaments and muscles connecting the femur with the pelvis and the joint would still stay in place!

Signs & symptoms
The symptoms are usually of pain in the groin area, worse on moving the hip joint or trying to weight-bear. I was told that the classic appearance of shortening and external rotation of the leg is not very common and only shows on a thin patient with a displaced fracture. The doctor did go through the mechanics of how this classic appearance occurs but lost me half way through his explanation! So I went to the clinical library & here are my findings for those purists who desperately want to know:

The shortening and external rotation is the result of abnormal pull of the muscles round the hip. The Iliopsoas muscle comes from the inside of the pelvis, crosses the front of the hip and pulls on the lesser trochanter which is slightly round the back of the medial side of the upper femur. Normally this flexes the hip joint because the whole femur moves in one piece. If the neck of the femur is broken the muscle just pulls the lesser trochanter forwards and twists the femoral shaft into external rotation. The short stabilizing Gluteus Medius and Gluteus Minimus muscles, from the outer pelvis to the greater trochanter, pull up on the now free femoral shaft, resulting in shortening.

Types of NOF Fractures

Fractures of the femoral head occur in one of three sites:

(1) Subcapital fracture which is across the neck of the femur immediately below the head.

(2) Trans-cervical fracture which usually about halfway down the neck. Like the subcapital fracture, if this fracture is displaced, the head of the femur is likely to lose its blood supply and results in necrosis and crumbling of the head later on. For this reason, a lot of these fractures are treated by replacement of the head by a metal implant, rather than trying to put together a fracture which will not heal and then collapse.

(3) Inter-trochanteric fracture which runs diagonally between the two trochanters. The area has an excellent blood supply and fractures here are unlikely to affect the viability of the head. They are usually treated by internal fixation, often with very good results.

Any of the above fractures may be undisplaced, grossly displaced or impacted. Apparently, injury to nerves and vessels is usually very rare.

So there you have it the first week is over but stayed tuned……..

1st day of PBM after the summer break!

After the summer break I was looking forward to getting back into my clinical placement & having some ‘hands on’ experience. First thing this morning I spoke to the Superintendent and discussed my objectives and how I could achieve them through organizing my time in A&E, orthopedic ward, theatre, etc. Well, there’s no better place than A&E to get back into the flow and it certainly was busy today! After a slow start, whilst I found my bearings, I was soon carrying out various x-ray examinations and actually managed to x-ray a fractured neck of femur (NOF)! Overall, I feel that the first day was a success & I’m looking forward to getting more experience of fractured NOF & linking the theory to clinical practice.