True Stories From Podiatric Residency

SDN Members don't see this ad. (About Ads)

Originally Posted by that1guyfromFL

The skin warmth, spiking fever and increasing swelling that many days after the injury makes me think infection.


Maybe a cellulitis secondary to the trauma?


Start an antibiotic with wide coverage and run blood cultures to make sure the kid isn't becoming septic.

This with a MRI would be my answer.

You never mentioned if there was a break in the skin or not...

I'm sorry that I can't in good conscience add anything to this thread (just a first year), but it's nice to see that my first instinct of broad spectrum antibiotics and subsequent MRI/cultures aren't deviating from the norm. This is a very cool thread.

No other systemic/constitutional signs?

MRI to r/o missed injury. CBC and ESR, arthrocentesis if values indicate. Ibuprofen and CAM until results come back. I'd consider a ped rheum consult for RF, ANA, HLA-B27 if septic joint is r/o and symptoms persist for a few weeks.

edit: not sure about when to start antibiotics. I would think that with fever and the physical exam described, if the ESR was high, you could justify starting Ab before you get the results of the initial aspirate (of which the sensitivity is something like 50%)... especially since this is a kid and joint destruction following an infection can be quick and deforming.

All very good ideas. No, there was no open wound at all. So this is how I proceeded. One thought was that it could be a salter harris I fracture of the distal tibia. But remember he was weightbearing after the injury for 2-3 days with no issues. The most important thing to do in this situation is rule out the most dangerous possibility which was a septic joint. He looked real sick and the hallmark of a septic joint is pain out of proportion and the distinct inability to move a joint AT ALL. Even with an ankle fracture they usually have some movement. I sent him across the parking lot for a STAT mri and blood work. CBC, SED Rate, and CRP were all elevated. The MRI showed a large ankle joint effusion with uptake in the distal tibia and talus. This was a septic joint. Now here is the dilemma. Do I admit the patient and do an emergent I&D? That is the easy part but that particular hospital isn't set up with pediatrics (peds hospitalist, infectious disease, etc) and other ancillary pediatric care. I immediately had him transferred to childrens hospital where he underwent an emergent I&D of the ankle. Blood cultures were positive and he was indeed septic. I spoke with a peds ortho doc the next morning and their thought was he probably wouldn't have lived another 24 hours. This little guy was SICK! He is still in the hospital but doing much better. He will be on long term IV antibiotics. I think the idea about tapping the joint is very valid but tapping the joint of a sick 10 year old in my office already in excruciating pain wouldn't have been easy or fun. And it would have served no purpose as he needed an emergent I&D anyway (white count). In a hospital setting where the patient wasn't so sick and you weren't sure what was going on, this would be completely appropriate.

And I learned a very important lesson. I really struggled with my ego on whether to transfer him or not. But in the end he received much more appropriate care at childrens than I could have given him. As surgeons, we often get caught up in whether or not we have the ability to do something. Sometimes it's not a matter of whether we can, but whether we should!

So how did the bacteria get in there with no open wound?

H. Influenza already in his system (ie sinusitis) reached the joint through the blood after the initial (and then repetitive) trauma? Or an adjacent soft tissue infection/abscess that was present prior to the initial injury?

This is quickly going over my head...

Originally Posted by jonwill

So how did the bacteria get in there with no open wound?

Most common cause of septic arthritis is hematogenous right?

Originally Posted by dtrack22

H. Influenza already in his system (ie sinusitis) reached the joint through the blood after the initial (and then repetitive) trauma? Or an adjacent soft tissue infection/abscess that was present prior to the initial injury?

This is quickly going over my head...

We aren't sure why but the theory is that he must have been bacteremic from something. When he sprained his ankle, all the fluid went to his ankle and bacteria seeded in the ankle joint. This is actually a really rare case and I'll probably never see it again. Even the guys at Childrens said they had never seen this in a pediatric ankle. So yes, acute hematogenous.

Originally Posted by jonwill

So how did the bacteria get in there with no open wound?

Septic arthritis is caused by germs that are carried by the blood from an infection elsewhere in the body (hematogenous spread). So the source could be from multiple places.

very inspiring jonwill, sounds like you saved his life and made a good call. This makes me even more excited and proud to have chosen podiatry!

Sent from my SPH-D600 using SDN Mobile

It is the start of a new residency year, and for me the start of my residency. Wow, hard to believe! I am on podiatry this month and have already been able to get some first-assist cases (formerly C-cases) and see some interesting things. I scrubbed in on a calc fx this weekend. The patient had been in Central America on vacation and was climbing some ancient Mayan ruins when he fell off of one of them (20 feet or so) and fractured the calc. He went to the hospital there and they put him in a very poorly padded and very tight cast. He decided to stay the remaining 4 days of his vacation, and then had the long flight home. Seeing him on his first day post-op he said the pain from the surgery was nothing compared to how much his foot hurt those 5 days in the cast.

So far things have been stressful, but awesome. Hopefully there are some other new residents on here that have some interesting stories!

Originally Posted by ldsrmdude

It is the start of a new residency year, and for me the start of my residency. Wow, hard to believe! I am on podiatry this month and have already been able to get some first-assist cases (formerly C-cases) and see some interesting things. I scrubbed in on a calc fx this weekend. The patient had been in Central America on vacation and was climbing some ancient Mayan ruins when he fell off of one of them (20 feet or so) and fractured the calc. He went to the hospital there and they put him in a very poorly padded and very tight cast. He decided to stay the remaining 4 days of his vacation, and then had the long flight home. Seeing him on his first day post-op he said the pain from the surgery was nothing compared to how much his foot hurt those 5 days in the cast.

So far things have been stressful, but awesome. Hopefully there are some other new residents on here that have some interesting stories!

where are you at? if I may ask that is.

Originally Posted by RockFoot

where are you at? if I may ask that is.

I'm at one of the Michigan programs.

Originally Posted by ldsrmdude

i'm at one of the michigan programs.

d-town!! Congrats man.

Another few busy weeks for me. Had a few cool cases. I got a calc fx in the ER last week while I was on call, then got to be there for the surgery, and I will be able to do the follow-up in the clinic as well, I hope. This was an 80 year old who stumbled in the garden and suffered a posterior avulsion type fracture. We tried to fix it percutaneously, but couldn't get the fragment down, so we opened it up posteriorly.

Had another interesting case that I think is almost resolved, and when it is, I'll post about it. We also have some good surgical cases coming up in the next few weeks too. As a first year resident, my senior resident will do the bigger cases, but I will still get a good amount of my own cases. I would be interested to hear from some other residents, especially first-years, on their interesting and cool cases.

I'll play.

Charcot Ankle fusion with frame, multiple lapius, forefoot slam's, kidner's, ankle fractures, posterior ankle scope, subtalar scope, calc fracture, TAR. Not a bad few weeks.

This is an awesome thread. Thank you for playing.

Originally Posted by densmore22

I'll play.

Charcot Ankle fusion with frame, multiple lapius, forefoot slam's, kidner's, ankle fractures, posterior ankle scope, subtalar scope, calc fracture, TAR. Not a bad few weeks.

Yep. I think that qualifies as "not a bad few weeks" .

Here you go, can give more specific details on some of these if you want, but just to show you what you can do at some programs.

Medial mal takedown with talar block allograft for OCD, Talar body fracture, a few arthroeresis, evans, calc slides, gastroc's, cotton's, STJ fusion, TNJ fusion, medial triples, true triples, os trigonum excision, neuroma's, LisFranc ORIF, rotational skin flaps, STSG's, Peroneal stops, skin biopsies (unfortunately my first diagnosed melnoma from a biopsy), tibial osteotomies, cole's, a few more frames, several more TAR's. Been a busy past few months (since we're on every other month, some of these are from May and most are from this month).

So I call a friend at another residency program, we are both newly second year residents. He was complaining about the difficulty of managing his new repsonsibilities and supervising the new first years, about how long his days have been. Then I start talking about the same on my end, and after about 30 seconds he isn't responding. I say his name, no response. I listed closer, and he is snoring on the other end of the phone.

Originally Posted by Creflo

So I call a friend at another residency program, we are both newly second year residents. He was complaining about the difficulty of managing his new repsonsibilities and supervising the new first years, about how long his days have been. Then I start talking about the same on my end, and after about 30 seconds he isn't responding. I say his name, no response. I listed closer, and he is snoring on the other end of the phone.

Haha, I've done that to my wife a few times this week already. At least I have an excuse now. I used to just have to sleep on the couch and beg for forgiveness the next morning.

Been able to do a few amps the past few days. Have done 2 TMA's, 2nd toe amp, 5th toe amp with partial 5th ray resection. Also I&D for gas, some bunions and some toes. Double scrubbed a Choparts amp, TTC fusion with IM nail, triple arthrodesis, flatfoot recon, and calc debridement with Abx bead placement. Also got a Lis Franc fx in the ER (just saw it in clinic today and it's going to be treated non-operatively. The lady isn't the best surgical candidate and the fx is not very displaced or comminuted.) I am on IM next month, so I'm trying to make the most out of my time on Pod this month. I'm also getting some decent scheduled stuff in the next few weeks as well, plus whatever decides to stroll in through the ER.

Originally Posted by densmore22

Here you go, can give more specific details on some of these if you want, but just to show you what you can do at some programs.

Medial mal takedown with talar block allograft for OCD, Talar body fracture, a few arthroeresis, evans, calc slides, gastroc's, cotton's, STJ fusion, TNJ fusion, medial triples, true triples, os trigonum excision, neuroma's, LisFranc ORIF, rotational skin flaps, STSG's, Peroneal stops, skin biopsies (unfortunately my first diagnosed melnoma from a biopsy), tibial osteotomies, cole's, a few more frames, several more TAR's. Been a busy past few months (since we're on every other month, some of these are from May and most are from this month).

I'm in a crazy busy practice (I saw 46 NEW patients this week) and our practice rarely sees or treats a lot of the pathology mentioned above. We do a fair amount of surgery, receive referrals from 2 ERs and hundreds of doctor's.

I noticed you did not mention bunionectomies, common forefoot procedures, etc. My question is where are the attendings getting all this pathology that requires these major procedures. Don'to get me wrong, we see and treat a lot of the pathology mentioned above, but it is definitely the exception and not the rule in our busy practice.

The Wookie says:

I wise old Jedi Master once told me that to be comfortable with the complex, one must master the basics. How comfortable do these training facilities make the Padawans, before asking them to take hand in the complex?

In the every day life of a Jedi, it is much more common to have to handle the basics while making one's way in the Galaxy. Even the most proficient of Jedi only handle the complex, rarely.

Lastly, although caring for the complex seems to garner more accolades, the true masters of the basics are those that can sleep well.

What are the hours like during residency? Is it similar to medschool residency?


Sent from my SCH-I535 using SDN Mobile

Originally Posted by DrShoegal

What are the hours like during residency? Is it similar to medschool residency?


Sent from my SCH-I535 using SDN Mobile

Lots of variability between programs and also if you are comparing it to allopathic/osteopathic residencies, there is a lot of variation in different specialties for their hours. The hours at my program are typically 6 am until 5 or 6 pm. Add time being on call to that plus time preparing for cases/presentations/research/academics/etc. We're not the most time-intense program, but we're definitely not the least either.

What are your weekends like?

Originally Posted by PADPM

I'm in a crazy busy practice (I saw 46 NEW patients this week) and our practice rarely sees or treats a lot of the pathology mentioned above. We do a fair amount of surgery, receive referrals from 2 ERs and hundreds of doctor's.

I noticed you did not mention bunionectomies, common forefoot procedures, etc. My question is where are the attendings getting all this pathology that requires these major procedures. Don'to get me wrong, we see and treat a lot of the pathology mentioned above, but it is definitely the exception and not the rule in our busy practice.

Our program had a few attendings that spent their time doing what they liked instead of focusing on being as busy as they could be. When you have an attending or two like that, and then a handful of others who see those patients on occasion, you get to scrub complex cases on a regular basis.

Who cares if that's not what a normal practice is like. That's not really the point of residency. The point of residency is to get comfortable providing the wide array of Podiatric care. And maybe to a smaller extent, figuring out if there is a sub-specialty that you like/are good at.

I see less complex cases than I did as a second and third year resident. That's for sure. But I'm probably split fairly evenly in the OR doing simple forefoot and what densmore22 mentioned. 50/50. Of course 2.5-3 days of clinic makes it feel like triples are fewer and farther between than they used to be...

Originally Posted by RockyIV

Who cares if that's not what a normal practice is like. That's not really the point of residency. The point of residency is to get comfortable providing the wide array of Podiatric care. And maybe to a smaller extent, figuring out if there is a sub-specialty that you like/are good at.

The Wookie says:
A wise old Jedi Master once told me that you should practice and be proficient at what you will be expected to do routine within your path as a Jedi. Focusing on mostly complex tasks, allows basics that you will use every day to slip. As a new Jedi, the complex will likely not find you as often as the simple, seemingly mundane. The basics are learned by the mundane and not the complex.

He also continued by saying that the point of training is to lay a solid foundation for the future. If you can't move a rock with the Force, how can you expect to learn to lift a starship as it sinks in the marsh?

Originally Posted by TheWookie

The Wookie says:
A wise old Jedi Master once told me that you should practice and be proficient at what you will be expected to do routine within your path as a Jedi. Focusing on mostly complex tasks, allows basics that you will use every day to slip. As a new Jedi, the complex will likely not find you as often as the simple, seemingly mundane. The basics are learned by the mundane and not the complex.

He also continued by saying that the point of training is to lay a solid foundation for the future. If you can't move a rock with the Force, how can you expect to learn to lift a starship as it sinks in the marsh?

You really make me laugh (I do appreciate your inter-galactic wisdom), but your post is "spot on".

Originally Posted by RockyIV

Our program had a few attendings that spent their time doing what they liked instead of focusing on being as busy as they could be. When you have an attending or two like that, and then a handful of others who see those patients on occasion, you get to scrub complex cases on a regular basis.

Who cares if that's not what a normal practice is like. That's not really the point of residency. The point of residency is to get comfortable providing the wide array of Podiatric care. And maybe to a smaller extent, figuring out if there is a sub-specialty that you like/are good at.

I see less complex cases than I did as a second and third year resident. That's for sure. But I'm probably split fairly evenly in the OR doing simple forefoot and what densmore22 mentioned. 50/50. Of course 2.5-3 days of clinic makes it feel like triples are fewer and farther between than they used to be...

I never commented on what's normal or not normal, nor did I state what the point of a residency is in my post.

I simply stated that although I have the training and have a busier than average practice, none of the docs in our program are performing these complex cases on a regular basis. I was simply asking where these attendings get all this major pathology??

Originally Posted by dyk343

What are your weekends like?

On call weekends mean rounding on inpatients for my program. That usually is a few hours Saturday/Sunday. Cases occasionally fall on the weekend as well (both scheduled and emergent). I have a case scheduled for this Saturday actually. I've had weekends where I was at the hospital for 12 hours a day, and had them where I have been there for 1 hour.
If I'm not on call, I have the weekend off. This is for on-service podiatry months. Off-service rotations vary.

Originally Posted by ldsrmdude

On call weekends mean rounding on inpatients for my program. That usually is a few hours Saturday/Sunday. Cases occasionally fall on the weekend as well (both scheduled and emergent). I have a case scheduled for this Saturday actually. I've had weekends where I was at the hospital for 12 hours a day, and had them where I have been there for 1 hour.
If I'm not on call, I have the weekend off. This is for on-service podiatry months. Off-service rotations vary.

Thanks for the reply!

Finally back on podiatry after a month of internal medicine. I have heard from some classmates who haven't been on podiatry at all so far, and have been on other rotations, and I am glad I chose a program that lets me be hands on early. Not saying it's the best way for everyone, but I like it better this way.

On internal medicine I worked a 24-hour shift every fourth day. While working overnight, my co-intern and I were the on call doctors for the hospital. We responded to calls for everything from chest pain, to strokes, to pronouncing deaths. I learned a lot during my month, and had a lot of interesting experiences, but I am glad to be back on podiatry.

We have had an unusual run of cases of hematogenous osteomyelitis of the calcaneus in some relatively young kids at the hospital I am at. We had 2 cases come in within just a few weeks apart from each other. I also had one of those days of ups and downs. I did a case the other day in the morning where everything seemed to just flow perfectly. The case went as planned and I feel like I did the best I have in any of the relatively few cases I have been involved with so far. Then later that evening we had an emergent case on a patient that I have been following since basically my first week of residency. We took him in to I&D an abscess that we saw on MRI, but when we opened it up, we found that most of the tissue in the entire foot was necrotic and non-viable. We started with a 2nd toe amp since that is what looked the worst clinically, but had to procede to a TMA, followed by a Lis Franc amputation, followed by a Choparts. When we found that even the Choparts didn't have viable tissue, we tracked the pus and necrosis proximally up into the leg, so we stopped at that point and got a consult from vascular surgery for a BKA. Mixed in with all of these things has been a healthy dose of hammertoes, bunions, I&D's, etc. We'll see what this weekend on call brings...

Originally Posted by ldsrmdude

We have had an unusual run of cases of hematogenous osteomyelitis of the calcaneus in some relatively young kids at the hospital I am at. We had 2 cases come in within just a few weeks apart from each other.

Any of those kids have sickle cell trait (or disease)?

Originally Posted by dtrack22

Any of those kids have sickle cell trait (or disease)?

Nope, nothing. All basically healthy (minus the osteo obviously).

Originally Posted by ldsrmdude

Nope, nothing. All basically healthy (minus the osteo obviously).

That had to be real interesting/puzzling. Thanks for sharing

Originally Posted by dtrack22

That had to be real interesting/puzzling. Thanks for sharing

Yeah, it was interesting. I have quickly read through some of the published material about hematogenous osteo of the calcaneus in kids. Relatively rare, and seems like about half proceed to surgery at some point. We're taking one of the cases to surgery coming up soon actually.

I am on my Emergency Room rotation this month and got told I "present patients like such a podiatrist." I had a lady come in from a motor vehicle accident and when I got the history and did the physical, I presented it to the ER attending something like this:
" I've got a 64 year-old female brought in by EMS following a motor vehicle accident. She was traveling approximately 40 mph when another motorist turned in front of her and she had a head-on collision. She didn't hit her head, or lose consciousness. She did hurt her right foot and ankle. She has tenderness on the lateral malleolus, base of the 5th metatarsal, and Lis Franc ligament. Oh, she is also complaining of crushing chest pain. But let me tell you more about the ankle..."
Apparently she thought the chest pain deserved a little more attention

Bump!

Please more stories!

Did a hallux amp the other day that was a bit interesting for the fact that it was secondary to melanoma. The poor lady was down to a single kidney due to cancer and now had a melanoma show up on her hallux.

Also had another case where I was glad that stuck to my guns. I saw a new patient in one of my attendings clinics who had a complaint of a "lump on the top of the foot." It seemed more firm than a ganglion cyst should feel, so when I presented to my attending I told him that I didn't think it was a ganglion, but some other soft tissue tumor. When he went to see the patient, his initial thought was ganglion, but I think he could tell I wasn't convinced, so he decided to aspirate it. Well, he only got a small amount of fluid, so we decided to get an MRI. We looked at the MRI and the report said it was likely a ganglion but cannot rule out other tumor. Well, we decided to remove it surgically. When we opened it up, it was very invasive and had infiltrated the subcutaneous tissue as well as nearby nerve. We're still waiting on the final path report, but if I had to guess I would say synovial sarcoma or fibrosarcoma. Those are just wild guesses though. Interesting case, and one where I am glad we didn't just assume it was a benign lump.

Originally Posted by ldsrmdude

Did a hallux amp the other day that was a bit interesting for the fact that it was secondary to melanoma. The poor lady was down to a single kidney due to cancer and now had a melanoma show up on her hallux.

Also had another case where I was glad that stuck to my guns. I saw a new patient in one of my attendings clinics who had a complaint of a "lump on the top of the foot." It seemed more firm than a ganglion cyst should feel, so when I presented to my attending I told him that I didn't think it was a ganglion, but some other soft tissue tumor. When he went to see the patient, his initial thought was ganglion, but I think he could tell I wasn't convinced, so he decided to aspirate it. Well, he only got a small amount of fluid, so we decided to get an MRI. We looked at the MRI and the report said it was likely a ganglion but cannot rule out other tumor. Well, we decided to remove it surgically. When we opened it up, it was very invasive and had infiltrated the subcutaneous tissue as well as nearby nerve. We're still waiting on the final path report, but if I had to guess I would say synovial sarcoma or fibrosarcoma. Those are just wild guesses though. Interesting case, and one where I am glad we didn't just assume it was a benign lump.

Interesting case and reminder to feel okay about sticking to our suspicions.

Originally Posted by ldsrmdude

Did a hallux amp the other day that was a bit interesting for the fact that it was secondary to melanoma. The poor lady was down to a single kidney due to cancer and now had a melanoma show up on her hallux.

Also had another case where I was glad that stuck to my guns. I saw a new patient in one of my attendings clinics who had a complaint of a "lump on the top of the foot." It seemed more firm than a ganglion cyst should feel, so when I presented to my attending I told him that I didn't think it was a ganglion, but some other soft tissue tumor. When he went to see the patient, his initial thought was ganglion, but I think he could tell I wasn't convinced, so he decided to aspirate it. Well, he only got a small amount of fluid, so we decided to get an MRI. We looked at the MRI and the report said it was likely a ganglion but cannot rule out other tumor. Well, we decided to remove it surgically. When we opened it up, it was very invasive and had infiltrated the subcutaneous tissue as well as nearby nerve. We're still waiting on the final path report, but if I had to guess I would say synovial sarcoma or fibrosarcoma. Those are just wild guesses though. Interesting case, and one where I am glad we didn't just assume it was a benign lump.

Interesting. Question, would it not be somewhat harmful to aspirate a tumor? I mean, I feel like the MRI should have been done first before attempting any sort of procedure. Obviously I don't know jack squat, just wondering.

Originally Posted by Shinobiz11

Interesting. Question, would it not be somewhat harmful to aspirate a tumor? I mean, I feel like the MRI should have been done first before attempting any sort of procedure. Obviously I don't know jack squat, just wondering.

Interesting question. There are theories that introducing a needle can spread cancerous cells, but I don't know about the accuracy of that statement. I'm not sure it's practical to order an MRI on every possible ganglion. There are some ganglion cysts that are firm and some gelatinous. Sometimes other lesions can mimic either of these types. That's why you have to get a thorough history, perform a good exam, determine if a ganglion cyst is likely to be present in that area, and of course listen to your instincts.

If you are going to aspirate, I believe it's more prudent to simply puncture the lesion without breaking through the opposite wall, to attempt not to spread any cells. It's also imperative to send ANY aspirate for cytology analysis, which should reveal of there are any malignant cells.

Originally Posted by PADPM

Interesting question. There are theories that introducing a needle can spread cancerous cells, but I don't know about the accuracy of that statement. I'm not sure it's practical to order an MRI on every possible ganglion. There are some ganglion cysts that are firm and some gelatinous. Sometimes other lesions can mimic either of these types. That's why you have to get a thorough history, perform a good exam, determine if a ganglion cyst is likely to be present in that area, and of course listen to your instincts.

If you are going to aspirate, I believe it's more prudent to simply puncture the lesion without breaking through the opposite wall, to attempt not to spread any cells. It's also imperative to send ANY aspirate for cytology analysis, which should reveal of there are any malignant cells.

Yeah that's what I was implying. I've heard that mechanical stimulation to cancer cells can causes malignancy. Right, but if you are unsure, isn't always better to be safe. The last time i shadowed Feli, we saw a ganglion cyst, but I believe he ordered an x-ray before the aspiration to confirm. Obviously an x-ray is way cheaper than an MRI, but better safe than sorry?

Originally Posted by Shinobiz11

Yeah that's what I was implying. I've heard that mechanical stimulation to cancer cells can causes malignancy. Right, but if you are unsure, isn't always better to be safe. The last time i shadowed Feli, we saw a ganglion cyst, but I believe he ordered an x-ray before the aspiration to confirm. Obviously an x-ray is way cheaper than an MRI, but better safe than sorry?

The only problem is that you have to ask what information an X-ray will give you when evaluating a soft tissue lesion. It may show an increase in soft tissue density, it may show if there are calcification, it may show if there are invasive/erosive bone changes, or it may show nothing. So although taking an X-ray is certainly prudent, it doesn't eliminate the possibility that a lesion is worrisome even though the films are ok. As a matter of fact, an MRI or diagnostic ultrasound is not always a guarantee of accuracy.

As you know, there is only one definitive way to make a diagnosis, and that is a biopsy.

So if you're really going to be cautious, a biopsy is your only choice. However, I still believe an accurate and careful aspiration can be beneficial and often eliminate a biopsy, without great risk.

Actually, I need to clarify. There are those who believe that any biopsy, whether it is needle or open, has the potential to spread cancer cells via "seeding". The theory is that every tissue cell contains a blood supply, and invading a lesion can spread the malignant cells via the blood, lymphatics, etc. There are some who say their observations are that they have seen many malignancies begin AFTER biopsy. They feel the biopsy spreads the cells since you can't perform a biopsy without some bleeding.

So their theory is that there needs to be a wide excision of a suspected lesion. So that alone is controversial, since that can result in a lot of unnecessary surgery.

So my point is that although you can never be completely sure, if you've seen a pathology hundreds of times, it's probably what you think. Aspirate or biopsy as you feel appropriate. If for some reason there ends up being a significant pathology, it's a strong bet that no one will feel you breached the standard of care.

If you see something unique amd funky, then you proceed with more caution. Judgement and experience along with gut feelings are all part of the decision making process. And sometimes there IS no right answer.

Originally Posted by PADPM

The only problem is that you have to ask what information an X-ray will give you when evaluating a soft tissue lesion. It may show an increase in soft tissue density, it may show if there are calcification, it may show if there are invasive/erosive bone changes, or it may show nothing. So although taking an X-ray is certainly prudent, it doesn't eliminate the possibility that a lesion is worrisome even though the films are ok. As a matter of fact, an MRI or diagnostic ultrasound is not always a guarantee of accuracy.

As you know, there is only one definitive way to make a diagnosis, and that is a biopsy.

So if you're really going to be cautious, a biopsy is your only choice. However, I still believe an accurate and careful aspiration can be beneficial and often eliminate a biopsy, without great risk.

Actually, I need to clarify. There are those who believe that any biopsy, whether it is needle or open, has the potential to spread cancer cells via "seeding". The theory is that every tissue cell contains a blood supply, and invading a lesion can spread the malignant cells via the blood, lymphatics, etc. There are some who say their observations are that they have seen many malignancies begin AFTER biopsy. They feel the biopsy spreads the cells since you can't perform a biopsy without some bleeding.

So their theory is that there needs to be a wide excision of a suspected lesion. So that alone is controversial, since that can result in a lot of unnecessary surgery.

So my point is that although you can never be completely sure, if you've seen a pathology hundreds of times, it's probably what you think. Aspirate or biopsy as you feel appropriate. If for some reason there ends up being a significant pathology, it's a strong bet that no one will feel you breached the standard of care.

If you see something unique amd funky, then you proceed with more caution. Judgement and experience along with gut feelings are all part of the decision making process. And sometimes there IS no right answer.

Epic.

Originally Posted by Shinobiz11

Epic.

Just curious, is your use of the word "epic" in this instance positive or negative/sarcastic? I am aware of the meanings of the word and the positive implications it can have. Just wasn't sure the context you were using.

I believe he was using it positively in regards to the knowledge bomb you just dropped on us.

And yes that is also meant in a good way.

But seriously, that was a great answer

Thank you PADPM for your input. I was hoping someone would have some insight into this issue.

Originally Posted by air bud

I believe he was using it positively in regards to the knowledge bomb you just dropped on us.

And yes that is also meant in a good way.

But seriously, that was a great answer

This.