Peg X-ray Pain: Show Me the Light!

x-ray positioningWhat Do You Think?

“Five percent of the people think; ten percent of the people think they think; and the other eighty-five percent would rather die than think.” – Thomas Edison

Do you always think about your options at each step of peg x-ray positioning? I know I don’t. I’ve been on autopilot. I’ve known that there’s a problem. Who doesn’t think that repeating x-rays is a problem? If you don’t, find another job. But instead of identifying a solution, I have fumbled through. Until now.


What Next?

x-ray positioning“It does not take much strength to do things, but it requires great strength to decide what to do.” – Elbert Hubbard

In the previous article of this series, I realised that it is not always possible to acquire a perfect image of the peg first time. The real problem, therefore, is having to repeat them multiple times. I went on to define three common scenarios that might lead to this: The Block, The Brick Wall, and The Mud. I asked what you would do in the latter two scenarios. Some of you came up with great alternative projections of the peg. In this article, I’m going to explore what my options are at this stage, and identify how they might result in further repeat peg x-rays.


Stop or Seek Help

x-ray positioningI have previously discussed lack of knowledge or skill as ‘a block’. Of course, this could happen at any stage of the x-raying process, and is more likely to occur as an examination becomes more challenging.

So What?

“To know that you do not know is the best. To think you know when you do not is a disease. Recognising this disease as a disease is to be free of it.” – Lao Tzu.

There is no shame in recognising my limitations, seeking advice or stopping the examination. If I don’t, then I’ll end up repeating more x-rays. Of course, this isn’t a long-term solution, it is just preferable to x-raying unnecessarily in the moment.


Take Two

x-ray positioningIn either scenario, I could simply try again. I could repeat the AP projection and hope the image turns out better. Lights, camera, action!

So What?

One definition of insanity is ‘doing the same thing over and over again, but expecting different results.’ Yes, I could try again. But what’s changed? If I positioned as I did before, I’d be resorting to insanity, and the second image would almost certainly be suboptimal as well. I’d be hoping the image turns out better. Take three!


x-ray positioningMix It Up

Carlton style! I could decide to scrap the AP projection of the peg, and try an alternative. Oblique projections, a Fuch’s view, the moving jaw technique, to name just a few examples. My choice here would obviously depend enormously on my patient, equipment, protocols, and the situation. It goes without saying that I could not move the head of a trauma patient.

So What?

If I chose to follow this option, then I would clearly have identified a problem. I’d have recognised that I was stuck behind a brick wall, or stuck in the mud. Good start! But what would happen if I tried an alternative view, and the image was again suboptimal? I’d then have two poor quality images of the peg, and be no further forward than I was at the start. I could try a third view, but at what point should I stop? It is easy to see how this option might quickly escalate into multiple peg x-ray repeats.


What’s Missing?

x-ray positioningLet’s recap. If I position attentively, or am forced to modify my technique, and the subsequent peg x-ray image is undiagnostic, I have a few options. The steps above are viable, but can all lead to multiple repeat images! So what’s missing?

There is one thing I neglected, one jewel in the crown, that is crucial in my quest to eliminate multiple peg x-ray repeats! What do you think it is? What am I not doing? Tell me in the comments.

Here’s a hint from Thomas Edison that might help you see the light.

“Just because something doesn’t do what you planned it to do in the first place doesn’t mean it’s useless…”

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