Men's Health Review and STIs

0:00:46.0 Professor Walden: Hey guys, it is Latrina and John. It is Professor Walden and I am here and we are going to have John Cannon talk to us about X-rays, radiology. This has been a big request and… Just a topic obviously, that I wanted to find someone who was more of an expert. John has that background in urgent care and along with many other things and I’ll let him talk about himself, but he’s going to give us some kind of general run-through of X-rays and so since this we’re gonna be really great, it might be a little lengthy so just kind of sit back, listen, take notes, if you have any questions along the way as you watch this, please feel free to let us know and then we’ll get back to you. Alright, John, you can take it away.

0:01:28.7 John Canion: Alright guys, John Cannon, I am a nurse practitioner, I spent a lot of time in emergency medicine, and you might have heard my dog yipping in the background, sorry about that. This is gonna be like a quick overview of X-rays, it’s not meant to be definitive by any stretch of the imagination, but I’ll give you a little link to the end to where I send most of my students when I want them to learn X-rays, and there’s a real good link at the end, which will give you a little more in-depth, deep dive into X-rays, but the biggest… First thing I need… I have nothing to disclose. The objectives of this, it’s just a basic overview of how to interpret X-rays, chest X-rays, abdomen, joints, what a nursemaids elbow is, splinting and common mistakes made with interpretation, and this is gonna be something for… Just kind of a basic thing, when you review a film, you’re responsible for everything on the film, everything. There’s some key mistakes we’ll get into later, on people missing things when they don’t review the entirety of the film, consistency is key, be consistent in how you review the film, and don’t miss the small for the large, and always do a post-reduction film if you reduce a joint or a fracture in order to ensure that you have good alignment, and then recognizing abnormal is more important than knowing what it is, so if you can see that there’s a problem, that’s more important than knowing exactly what the problem is.

0:03:04.6 John Canion: We have specialists for a reason, and those specialists can figure it out, but if you get a X-ray report back and it’s normal and you look at the film and you see something bad, you need to call the radiologist and be like, “Hey, I see something here, I’m not sure what it is, can you help me?” And he may say, “Yeah, that’s a normal abnormal”, and that’s the case that you move on, but you need to make sure you they draw attention to it and make sure that they have some kind of notation in it and the documentation. On chest X-rays, resident Pneumothorax is a problem. And that’s the Scapula. People will think there’s a Pneumothorax looking at the scapular line, we’ll go over that. The humeral head is the most often missed fracture on a chest X-ray, because people don’t look at the top of the humerus, they’re just looking at the lungs and the heart, they’ll miss an AC separation, shoulder dislocation, cardiomegaly is only on the a PA, a posterior to anterior view, so if you get a it portable, you can’t truly measure cardiomegaly now if they have a massive heart of course you can could say it is, but how to measure it? The only way to do it is on the posterior to anterior view, rib series to do or not to do… We’ll get into that.

0:04:09.8 John Canion: This is what your basic chest X-ray looks like. Oh good, okay, can you this use this, manubriam, your aortic arch, they outline the nice lining of the lungs, so you get the apex, the bases, costophrenic angle, the bases, you get the heart, you can see that, see what they aortic notches arches, gives a pretty good idea and then the stomach comes here, and there’s the gastric bubble always, always on the left. You come around, and it gives you a nice little picture of where the lobes are, and remember the lobes do overlap, so when you’re looking through something that’s here, is not necessarily in the upper lobe, most likely in the middle lobe, could be, could be lower lobe as they overlap a little bit. Make sure you look at everything, so we’re gonna look at the humeral head, the humerus, scapula, clavicles, everything that’s in the picture is what we’re responsible for, so that’s what a normal chest X-ray looks like.

0:05:03.8 John Canion: We go through, start at the apexes, come down to the sides, costophrenic angle along the base, back up along your border, you like the heart border, come back to the aortic notch, go down the other side. However, you determine to look at the X-rays, as long as you’re consistent in how you do it, you’ll be successful. So we look at the problem here, and I’m gonna give you a second to kinda review the film, and see if you can see what where the problem is, and we can always go back to the normal chest X-ray, that’s the normal, you can see there’s an abnormality there, what we’re looking at is the mediastinum, this gap here, and when we go back to the measurement, the mediastinum is measured across the aortic notch, come back here the patient has a very large mediastinum and when we’re looking at mediastinal widening, it’s when the mediastinum is greater than eight centimeters at the aortic arch in adults, or in children, it’s greater than a quarter, and that’s how you decide if they have mediastinal widening, very simple. What we’re looking at here, if you can see the abnormal, give you a second to look at it, and remember, this is not necessarily recognize the problem so much as recognizing the abnormal, and if you can see there’s a significant difference in the base.

0:06:24.1 John Canion: When we get down to the base, base is flat, goes to the sharp costophrenic angle, there is a blunting and of the costophrenic angle here, which is consistent with a pleural effusion, so this is… Imaging is very good at detecting pleural effusion, but not the type of the effusion, and as we know, there’s multiple causes for effusions, it can be transudative or exudative, we cannot be evaluated by imaging alone, this is something that we need to tap in order to evaluate. When looking at the chest X-ray again, recognizing abnormal is the most important part.

0:07:00.2 John Canion: Give me a second to look at that. Alright, so what we’re looking at here is a pneumothorax. So this, if you look and we’ll go back to the normal chest x-ray just to get a chance, you can see there are pulmonary markings extending out all the way to the edge of the lungs, and there should be not always easy to see on a presentation, but these is pulmonary vasculature and it should extend all the way out to the edges of the lung, Okay, and when you go back to the pneumothorax, there’s no pulmonary vasculature out in the lung, it this is clean space.

0:07:41.0 John Canion: So there’s nothing there. And remember, on X-rays, black is air and white is density. So the more white something is, the more dense something is, the more tissue is in the way, okay, which is why it’s easy to see lung fields. That’s what a pneumothorax will look like. Often caused by blunt penetrating trauma, can be caused by damage to underlying tissues. So just giving you an idea. So we’re gonna look here, let’s see if we can’t figure out what’s going on in this chest x-ray. Remember, recognizing the abnormal is often more important than recognizing or knowing what it is, okay. Eventually, as you get used to reading films, you’ll become more used to determining what the problem is, and if as you see the patient has an infiltrate here, okay, we’ve got a nice little pneumonia brewing right. And the rest of the X-ray is pretty normal, although it is poor quality film, but I had to zoom in a bit so you could get a better view of the infiltrate, so we’re gonna look here. And again, we have the abnormality that we just need to make sure that we look at and we see them, but don’t forget to review the entirety of the film. Another infiltrate, this one is more subtle, okay. So you get a little bit here, more subtle.

0:09:12.2 John Canion: Now interesting on this, you can also see nipple markings, so you have here, this appears to be a nodule and here appears to be a nodule, when you have something like that, you can see the breast tissue coming down here, you can mark those if you are not sure if it’s a nodule or not, you can have radiology mark where the nipples are to ensure that you’re not misdiagnosing a nodule when you see that. That’s something that’s kind of important to know, and also on the lateral, you will not see it enough, obviously, but this is something that you need to be aware of. The infiltrate is right here. It’s almost a wedge shape. Okay, another wedge shaped, infiltrate. Nice bright arrows there to help us out. I’ll give you a second on this one since there’s no arrows helping us out.

0:10:11.6 John Canion: This is actually a normal chest X-ray with the exception of a clavicle fracture, and this gets missed easily, this is one that it was actually missed by the radiologist, okay. He called this a normal film, and this is not a normal film, we miss missed the clavicle fracture, okay? So that’s something you have to look at the entirety of the film and make sure you’re consistent with your reading in order to make sure that you don’t miss. A pretty good one.

0:10:39.6 John Canion: And another one here, this patient has a nice widening mediastinum, and this looks like a mass right here. Okay, that’s gonna be a problem. We’re gonna have to CT that one and figure out what’s going on. Go again, take a little look here. Alright, so this one actually is a pretty interesting chest X-ray, so what you’ve got here is most likely the diaphragm here, and the a diaphragm here, and it looks like you have free air under the diaphragm, so that appears to be the bottom of the diaphragm, and it looks like there’s air there and there’s air there, which would lead us to believe that the patient has a perforated bowel or free air in the abdomen. Okay, that’s a little bit of an issue and it needs to be checked. When, when you get an X-ray on somebody who comes in and you see this, there should never be air underneath on the right ever, because that’s where your liver is, that’s why it’s important to note that the gastric bubble is on the left… If you ever see what appears to be air under the diaphragm on the right, that assumes that the patient has a perforated bowel until proven otherwise, so we have to CT that patient and ensure that there’s no perforation.

0:11:55.6 John Canion: Yes, don’t be distracted by the big and miss the small like the clavicle fracture. Alright so abdominal views. So it’s very, very limited reason to get an abdominal view anymore, okay. Used to do them for a lot… We don’t do it a whole lot anymore. The only indication is really from an acute standpoint to do an abdominal film or bowel obstruction, you’re looking for bowel obstruction, you’re looking for free air or you’re checking tube placement. That’s about it. Okay, so what we’re looking at here, normal abdomen, okay, so you have a stomach shadow on the left, you have normal or what they call non-specific small bowel gas pattern, and you have the liver up here, which is a solid organ, which is why you have no air there, that’s why it’s wider than the rest of the belly, and that should always be on the right… Of course, unless you have something, weird like situs inversus, okay. Everything else looks good. Gives you a little bit idea of where things are. Okay, so what we’re looking at here is a two view or upright abdomen. Give you a second to look at that.

0:13:07.6 John Canion: Okay, so what we have here is a pretty classic bowel obstruction pat pattern, so you have what they call air fluid levels where it’s flat on the bottom and round on the top. And on an upright, you should always see that as the gastric bubble, but never in the rest of the bowel, okay. So the rest of the bowel should not have that pattern, it should have a non-specific pattern like this, okay. So when we go to this, it’s flat on the bottom, round at the top, you also have what looks like a little bit of coin stacking, so if you look at this, it looks like a roll of coins on the side, that’s another indication of bowel obstruction, okay. Again, really, really good image of air fluid levels, flat on the bottom, round on the top, it doesn’t look like a very good picture for coin stacking, have a little blood, maybe a little bit there, but not much.

0:14:02.7 John Canion: This is just what you need to look at when you’re looking at a belly, that’s one of the important things that we’re looking at, okay. So here’s another one, great example of air fluid levels. Flat all across the bottom, rounded on the top. The other thing that’s really interesting here is you have air on the right, okay. Any time you have air on the right, it means perforation or obstruction, I’m sorry, perforation. You have to assume perforation, there’s some kind of air, free air in the abdomen that’s not supposed to be there. That is very, very bad. Should not be there. Okay, so we go back. Original picture, there’s your liver, there’s no air, gastric couple of bubbles on the left, Okay, back to that, that’s a nasty one, that person probably died.

0:14:48.1 John Canion: Alright, so here, what happens if you have somebody who can’t sit upright, you get what’s called a lateral decubitus, have the patient lay on their side and you get that it’s marked by the X-ray interpreter tapes as the decubitus for us, they lay on their side, so this way is now up, which they’ve noted with the arrows, and then you get a nice flat pattern which shows you have a bowel obstruction. This is most likely free air because you have free air up here and you have an obstructive pattern down here, so this is most likely free air pushing the liver down out of the way. Alright, when you go to joints, how do you name your joints? That’s important that which you need to know that. So when you talk to the orthopedist, you sound like you know what you’re talking about. The scaphoid fracture is the most commonly missed fracture in the wrist and hand, and it is the one that is the most debilitating, so you have to watch for it.

0:15:46.5 John Canion: One of the most common foot fractures, ankle eversion, inversion injuries. What’s important, we’ll look at hips and elbows as well, okay. So let’s go first, wrist, this is the scaphoid, these are the names of the bones in the wrist, there’s a nice little acronym for it, but in the most cases in family practice, you’re not gonna need to remember that, so it’s a non-issue. The big one is the scaphoid. The reason that that’s important is the blood slide, but blood supply goes this way, so if you get a fracture across, you lose blood supply to you get a vascular necrosis of the distal end of the scaphoid which reduces the mobility in your wrist, and if it happens on the dominant hand, it pays out significantly in malpractice, it’s something you need to be aware of, okay.

0:16:35.2 John Canion: Alright, so the most common missed carpal fracture is the scaphoid, which we talked about, and this is what you call the anatomical snuff box, so you can put your hand out and you can see where the anatomical snuff box is, any time you have tenderness along the anatomical snuff box, you assume there’s a scaphoid fracture until proven otherwise, okay. A plain film which does not show a scaphoid fracture does not guarantee that there is not a scaphoid fracture, so what that means is if you have to get either a scaphoid view or a CT to ensure, okay. I’m gonna say that again, a normal x-ray does not eliminate the possibility of a scaphoid fracture, if you suspect the a scaphoid fracture, you need scaphoid dependent views or CT to confirm.

0:17:27.0 John Canion: Okay, okay. So if you do end up having a fracture there, a splint with a thumb tight spike a tight splints, and we’re not gonna go super in-depth into splints on this, but there’s something where you splint along the thumb and into the wrist to keep it from moving. Failure to catch a scaphoid fracture can lead to chronic arthritis pains, of course, reduced range of motion. This is a scaphoid fracture, so when you look right across the middle of the scaphoid bone, there’s a fracture, remember fracture is always black on white, and there should always be an edge of the bone that is disturbed. Okay, that makes sense. Okay, let’s go back one second. We didn’t do this. Alright, so we need to do how to name joints. Okay, I’m not gonna do this like this. If you look at your hand, your joint is always named from the proximal bone to the distal bone, so this joint would be the metacarpophalangeal joint or the MCP.

0:18:34.0 John Canion: This joint would be a interphalangeal joint because it’s between two phalanxes. Again, interphalangeal joint, when you have multiple interphalangeal joints, you have a distal interphalangeal joint and you have a proximal interphalangeal joint, okay. Of course, the only digit which does not have that is the thumb and in that case, it’s just called the IP or interphalangeal joint. So makes sense? Metacarpal phalangeal. So by appropriate naming the wrist is actually the radio-carpal joint, nobody calls it that, everybody calls it the wrist. Make sure when you name things, if you have an injury in the appropriate place, you name it by the appropriate section. This is dorsal, the back of the hand, volar is the palmar aspect of the hand. Palmar is also okay. Dorsal, volar. The reason that’s important is when you have injuries to that side of the hand, it let’s you know whether it’s a flexor tendon injury or an extensor tendon injury, okay. And that’s important when it comes to mobility and determining length of time on how soon a patient needs to get in to get their tendon repair, should they have loss of function, okay.

0:19:48.9 John Canion: Back to the scaphoid… Oh. Okay. We see what a scaphoid fracture looks like, we see black on white, it’s always what we’re looking for with a fracture. Foot, there’s a nice diagram of the foot, I’m gonna leave that up there for a second so you can get a little idea of where everything is. Okay. Alright. The most common fracture in the foot is the base of the fifth metatarsal. Okay? So what you have is what’s called the most common place to get it is right here, and this is an avulsion fracture. If you have what’s called a Jones fracture, which goes along the proximal end of the fifth metatarsal, you have a surgical fracture. So, avulsion fracture on the tip, no surgery. Jones fracture require surgery. You have to know the difference between the two. It may not come back read from the radiologist as a Jones fracture, if the fracture comes along the neck of the fifth metatarsal, it requires surgery, has to have a pin placed. Requires surgery. This is a surgical treatment only.

0:21:11.5 John Canion: Avulsion fracture will often get a fracture here, we don’t do anything for that. A fracture here, surgery, okay? Has to has to have to have surgery. And you need to be able to recognize the difference between the two, because some of our colleagues don’t. I’ve had reports come back that no further intervention is required, and so you get in to see the orthopedist. Makes sense? That’s your Jones fracture, right across. Okay. That’s the one that causes… Require surgery. Require surgery because of slow healing that’s associated with it. Must be seen by orthopedics, must must must. Elbow. We’re gonna get into the elbow. Elbow is, of course, a very important joint as they all are. There’s a nice little an anatomical reference point for you, I’ll leave that up for a second. And it also shows a good, nice, normal elbow. When we look at the elbow, we look at fat pad signs when we look for injuries. The anterior fat pad is here, posterior fat pad is here. There should be very minimal. It’s very difficult to see on these films.

0:22:26.7 John Canion: If you have an anterior fat pad or a posterior fat pad and you cannot find a fracture on the plain film, you assume an occult radial head fracture. So when we go to the next film, if we look, we have what’s called a “sail sign,” looks like a sail here, and you have this here, the lightening of that is swelling in the joint, which makes us assume a radial head fracture. So you treat it as such until they can be followed up with an orthopedist, or they can get appropriate imaging to ensure. And anybody that has this, just assume it’s a fracture. We can see again here, the radial head is very, very smooth, looks good, very difficult that I don’t see a fracture there. But the sail sign and the posterior fat pad show us that there’s an occult radial head fracture, so that needs to be treated as a fracture, it needs to be… Have a long arm posterior splint placed, put in a sling till they can follow-up with an orthopedist. Now, as we know, the vast majority of orthopedists will just treat this with a sling, but until they see them, we splint them and have them follow-up.

0:23:34.8 John Canion: Unless you speak to them, which is okay too. If you call and talk to them and they say splint, follow-up in the… I’m sorry, sling and follow-up in the office is okay too, ’cause most of the time we are not casting these anymore. Alright. So again, look at the elbow, you get the sail sign where it comes out like a sail, anterior fat pad, posterior fat pad. Now, this is in a kid, right, no obvious fracture, you’ve got growth plate growth plate, so no obvious fracture there. The most common fracture you have in an elbow in a child, which is not a radial head fracture, it’s a supracondylar fracture. The kid will come in with pain and swelling to the elbow, if they have swelling, you assume fracture. Assume it’s broken, until otherwise. Even if the story is okay for a nursemaid’s, if they’re swelling, always X-ray the elbow, especially in kids. Okay, there we go. For the elbow.

0:24:31.5 John Canion: So, supracondylar fracture. That’s where you’re gonna get the break. That’s what we’re talking about when we talk about a supracondylar fracture, and that’s the most common fracture in children for elbow fractures. And often, but not always require surgery. Is displaced, it’s gonna require surgery, depending upon how severely displaced as is, depends on where they need to be sent. Most general orthopedists can handle a mildly displaced supracondylar fracture. Alright. This is a supracondylar fracture. This is one that’s severely displaced and will need to be seen most likely at a dedicated facility. That’s pretty bad. Alright. So when we look, here’s our anterior line, you can see here there’s actually a fracture across. And you can see it here too. But this is non-displaced, your alignment is intact. When your alignment’s intact, this one probably not even gonna need surgery ’cause it’s so well non-displaced. Lucky kiddo, right?

0:25:41.8 John Canion: And that’s the anterior humeral line. Probably should’ve put those in the other order. Which shows the capitellum, the humerus lined up well. And that’s what you’re looking at here, the anterior humeral line. When that is lined up well, generally a non-displaced fracture, which is what we have here. Okay? The answer to this is always pain and swelling, if you have a supracondylar fracture. We always assume supracondylar with swelling. Do not manipulate an elbow until, if they’re swelling, until you have a film. Always, always, always, always. And there’s two types of supracondylar fractures. The distal fragment’s displaced anteriorly, which is exceptionally rare, and the extension is, which is the distal fragment displaced posteriorly, which is the vast majority of them. It’s just a nice little extra information. Hand, here’s a review of the hand. Again, the thing that we’re looking at most importantly is the scaphoid, that’s the one you cannot miss. If you have tenderness, you need to get it reviewed. So wrist or hand, you have to pay attention to the scaphoid.

0:26:58.3 John Canion: Right, so here’s a normal X-ray of the hand. No, I’m sorry, that’s not a normal X-ray of the hand. I’m gonna give you all a chance to look at it and see what’s going on. What we have here is called a boxer’s fracture. So you have a depressed fracture of the distal end of the fifth metacarpal, and this only happens from punching things, which is why it’s called a boxer’s fracture. We’re looking at there, it needs to be reduced, will probably most likely need a pin because of the severity of displacement. This is the one where somebody gets mad, punches the window, punches the wall, punches the car, whatever they happen to punch. And it’s apply named. Pediatrics. The nursemaid elbow. This is something we need to talk about, we didn’t talk about before. X-ray is unnecessary with appropriate history and no swelling. If you are not sure on a pediatric joint anywhere, always get a comparison view. Always, always, always get a comparison view. It will allow you to determine whether or not the patient actually has a fracture versus a normal growth plate.

0:28:20.5 John Canion: Salter fractures. Something we need to talk about that we already discussed, supracondylar fractures. Two-view skulls are completely unhelpful in diagnosing anything in pediatrics. However, we often use them for parents that have a child who hit their head and they don’t understand or freaked out by PECARN rules, which are the rules to reduce utilisation of head CTs in children. So if the PECARN is negative, sometimes you’ll see the provider get a two-view of the skull in order to make the mom feel better. It does not add any value to the case in most cases. There is a less than 1% chance of you finding a skull fracture on a two-view skull, and Salter fractures are growth plate fractures, and what that means… Let’s see if we have a nice little picture. We do. Okay, so the Salter-Harris type fracture is not based off of a physician’s name, except the Harris part, the Salter is how to remember the fracture. So they are a one, two, three, four, five type fracture. This is normal. A Salter-Harris type one is a slipped. So the S is for slipped. This moves to the side, that’s not aligned well, that’s not a great picture of it. Next one is that A, it’s above the growth plate. Okay, make sense?

0:29:47.5 John Canion: L is lower, so it’s on the lower end. T is through, and the E is every cell, which means it’s impacted, it’s pushed down. The growth plate normally looks like this and it’s pushed down on itself. Difficult to determine this one unless you have a comparison view. So that’s a difficult one unless you’ve got a child who’s super young and should have wide growth plates. If you had a 14, 15-year-old, it may be difficult to tell without a comparison. So it’s slipped, above, lower, through, every cell and the R is so you remember it all. That’s what the Salter is for, one, two, three, four, five. Slipped, above, lower, through, every cell. The nursemaid’s elbow is a subluxation of the radial head. Okay, make sense? We get a nice little anatomic review there. This is the classic presentation of the nursemaid’s elbow. Generally under four years old, more common in boys than in girls, but does happen in girls, and it’s… The reason that we call it this is the nursemaids in England used to walk along with the child and pull on their arm, jerk on their arm to get them to go, and it would…

0:31:16.4 John Canion: You would get your subluxation of the radial head when they did the pulling motion. If there is no history of trauma, there’s no swelling in the elbow, and the history is consistent with a nursemaid’s, it’s okay to reduce without film. Now, there’s two ways to reduce a nursemaid’s. And it’s… I’m gonna see if I can get it on the camera. It’s… Alright, so you put your thumb over the radial head, apply pressure, and you pronate, supinate, flex. The other way to do it is called hyper-pronation. So you’re gonna put your thumb on the radial head and hyper-pronate, and that’ll reduce the nursemaid’s. Also, hyper-pronation is becoming the more preferred technique because it’s easier to do and a lot easier to have reduction. If you’re successful, you should feel a click or a pop and you should have the child feeling better and using its elbow again within… I don’t know, 20, 25 minutes. Half the latest. Generally, within 5 to 10, they’re feeling better once they have… They realize their arm doesn’t hurt. What you can do is have the parent hug the child with the non-injured arm blocked under the hug, leave only the injured arm open after reduction to see if they’ll grip and play with things. Once they start moving it and realising it doesn’t hurt, then they’ll go back to normal.

0:32:48.8 John Canion: Right. Do not reduce, or manipulate if any history of fall, okay to reduce based on history, pronate supinate flex, or hyperpronation, you should feel a popping sensation. Splinting. This is a nice little guide to splinting, I would recommend that if you do not know how to splint, you take a course or have someone show you. They’re pretty simple to do, but this is something you just have to understand how it works in order to do it. There’s a posterior splint, which is behind. Same on the leg, there’s a sugar tong which goes around, looks like a sugar tong, which will go from one side around to the other side. And there’s a volar splint, which is here, there’s a thumb spica which comes… Oh, I’m sorry, I’m getting off camera. Comes like this, and down to the wrist to limit movement of the thumb. These kinds of splints are beneficial in fractures, or if you suspect a fracture and are not sure. If you get a film back and you suspect a fracture and you’re not sure, it’s better and always safer to treat as a fracture until proven otherwise.

0:33:57.0 John Canion: So, when you split you always splint the joint above and below if you can. If you have a fracture mid-forearm, you want to splint the wrist and elbow, which is why we do the pulling of posterior, or sugar tong. Makes sense? Okay? So, we have… Hold on a second, let me close the door. Maybe that’ll get the yippy dog to stop a little bit. And most common for splinting volars, metacarpal fractures, ulnar gutter, which is this way. It’s for the boxer’s fracture, thumb spica for the thumb, or the scaphoid sugar tong, midshaft distal to distal extremity, along posterior proximal distal extremity or proximal extremity sugar tong posterior as listed. And always, always the preference of your orthopedist. If your orthopedist has a different preference, then we do as the orthopedist wants, especially if we’re referring to them. Any unstable fracture, if you’re unsure, if you don’t know how to appropriate describe something, text, text the image.

0:35:03.7 John Canion: If you’re going to text the image, please use HIPAA-compliant texting, or ensure that there’s no patient identifiers. HIPPA-compliant, the fact the texting is always safest for you, the patient and the consultants, you ensure that nobody ends up with a big nice $50,000 HIPAA compliance issue. If you don’t know, it’s always better to consult, always better to consult. And it’s exceptionally easier now that everybody has cell phones, and the quality of the images you can capture on your cell phone and send it to an orthopedist are phenomenal. So if you’re not sure, consult. Open fractures always require emergent orthopedic referral, and appropriate antibiotic therapy. Splint appropriately, cover the area that’s open with a moist-to-dry dressing, start them on appropriate antibiotics, give them the appropriate tetanus, etcetera, and refer them immediately to orthopedic… Whichever emergency department they use.

0:36:04.6 John Canion: This is what I like to send all my students to, there’s a lovely, lovely Primer course that is free at the University of Virginia, and there’s a link there, I’m gonna leave that up for a little bit. This is something that everybody, everybody should do. I also think there’s a distinct value to reviewing every single film that you get back. And even if you’re in family practice and you’re waiting on the radiologist interpretation, I still think it’s a great value for you to look because you have the ability to know what’s going on with the patient. You know what you’re looking for. And you have the ability to look at that. And the radiologist, everybody’s human, everybody misses things. So if you take the time to review your films, you’ll get better at it as you do it. And that’s about all we have. We’ll get in the references there. Please, please, please take advantage of the University of Virginia radiology course, it’s free, and it’s a great course.

0:37:08.6 Professor Walden: Awesome. Thank you, John. Alright. Guys, we’re gonna type that in for you to make sure that we don’t lose that and make sure that we get that course out there for everyone, but we will talk to you later. I appreciate it.