Describing fractures on imaging

I'm still uneasy around x-rays. If it's not a clear cut case of whatever, it can feel like a magic-eye picture and whilst the Consultant's eyes bore into my temples I am left saying "uhhhhhhh".

One thing I picked up on the plastics rotation was describing fractures. Like so may things in medicine, and imaging in particular, there is a step-wise way to avoid missing out on any important details:

Always include the name of the patient, what kind of image it is, its orientation and when it was taken
Is it open or closed (does it fully penetrate the surrounding soft tissue)?
Is it transverse, oblique or spiral (exactly as the terms sound)?
Give the anatomical location of the bone involved and include the bone anatomy, too
Is there any joint (articular surface) involvement?
It is comminuted (more than two pieces)?

i.e. "This is a plain anterio-posterior radiograph of the right hand of John Smith, taken earlier today. There is a closed, oblique, mid-shaft fracture of the third metacarpal. There is no articular involvement and it is not comminuted"

Oh, come on!

So, here I am half-way through my plastic surgery placement and loving it.

It took a bit of time to get started, but mainly because I didn't play to my strengths enough and was a bit of a wallflower.

No longer.

I'm getting on well with the team and it's nice to be getting stuck in with history taking, wound washout and dressing, bleeding and cannulating like a mo' fo' and seeing some fascinating cases.

I've really been boning up on my theory, too. I can talk on the difference between an FDP versus and FDS injury, the need for aggressive management of necrotising fasciitis (or "nec fash" as we say in plastics :P), the implications of loss of sensation of different digits or why surgery is so much better than medicine (I'm still not entirely sold on that argument...)

Sitting with the consultant in his clinic still generates existential dread, though. I'm not sure that ever changes, to be fair, as I have seen SHOs and SpRs with an expression I recognise - the "oh god, I have no idea" face. I thought I was doing okay on my last clinic... Only to have One Of Those Questions come up:

Mr Hand: "What test am I asking the patient to perform?"

(the patient is making the familiar "inverted prayer" I know is Phalen's test)

Me: "Phalen's test"

Mr Hand: "And what is the positive Phalen's sign?"

Me: (silently sighing with relief) "Pain or tingling in the hands"

Mr Hand: "And when did Phalen write his paper on this test?"

Me: (OMFGWTFBBQ) "No idea, sorry"

I almost laughed because I thought he was being hyperbolic. Turns out, not so much.

*sigh*

The first cut is the deepest

I don't know who said it, but they were wrong. And also kinda right.

This week has been my first week on attached to a surgical firm at St Clabert's and it's been a reminder of what I know and what I don't.

The first point of call was that, until this week, I'd never been further than the anaesthetics room in theatres (other than as a patient). In ward life you know of theatre people and maybe have the occasional tussle in recovery, generally about how you're not taking the patient who is groaning in pain and who's BP is in their boots back to the ward. But I'd never before donned scrubs, clogs and a hat and walked into theatre. It is a strange, controlled, precise place compared to the ward. It was refreshing to experience this change of pace and bear witness to a kind of calm teamwork that I've not seen much of before now.

And the first cut. I realised, when I saw the scalpel go in, that I had never seen this happen before, either. Don't misunderstand, I've assisted in plenty of drain insertions, ascitic taps, biopsies, endoscopies et al, but never seen a person cleaned, draped and then surgically incised. It was amazing. I didn't expect it to be a notable experience, but it left me literally agape (and then when I realised, quickly stoical - I mean, no-one wants to look like a noob in theatre).

This week has quickly taken me out of my comfort zone as anatomy is one of my weaker points and being quizzed about specific muscles and their attachments and insertions and innervations and (god forbid) arterial supply or venous drainage is just awful for me. I've had to claim ignorance and face disapproval more this week than my ego is frankly comfortable with and had to accept I really need to spend more time with Netter if I want to get the most out of this placement.

The high points have (unsurprisingly) been history-taking, clerking, examinations and ward life (both pre-op and post-op). I fully expected this to be the case, given my previous life. I love being on a ward, talking to patients, sitting with them to take a history, busting out the stethoscope, percussing, palpating, the whole nine yards. Which I guess says something about my medical bent.

So far this has been a good placement and I have several weeks to go, so more time to get comfortable in theatre, maybe even scrub in and hold a retractor or two, more time to get my muscles and nerves straight in my head, more time to reinforce the ward skills I have brought with me.

Now if you'll excuse me I have an important meeting with the intrinsic muscles of the hand...