"My Precious" - Fractured Radial Head & Uncertain Future

This week we catch up with Bones and meet a man with a broken bone who has a potentially arrhythmogenic heart.

Bones & The Quest for the Missing Ring

"A long time ago, in a Casualty far, far away...."

Bones was the cartoon creation of Rowan, an anaesthetic registrar who worked in the Casualty Department of the Preston and Northcote Community Hospital (in Melbourne, Australia) in the 1980's. This was the PC (pre computer) era; it was also the Walkman era (the Walkman was a portable cassette player introduced in 1979).

Book reading was a major recreation for many persons, including Bones - science fiction or fantasy epics were among his favourites. He particularly liked Tolkien's "The Lord of the Rings", and was an addict (and adept) at the role playing board game "Dungeons and Dragons". This cartoon shows Bones and his quest for his lost "precious"

Figure 1

R_0051: The Aftermath of a Injured Elbow 

A 33 year old man injured his left elbow after falling off a skateboard. The clinical diagnosis was a possible elbow dislocation, and an ECG was recorded in preparation for reduction under anaesthesia. An Xray and CT scan of the elbow is shown in Figure 2 and Figure 3 shows the ECG.

Figure 2

Figure 2

Figure 3

+ What are the main findings?

  • Sinus rhythm is present, with a heart rate of about 68 beats per minute. The PR interval is about 0.24 seconds, and the QRS and QT intervals are normal.
  • The frontal plane QRS axis is normal. The transition zone is in Lead V3
  • The following findings initially suggest right bundle branch block (RBBB):
  • S wave in Lead V6, and a (probable) very small S wave in Lead I
  • A triphasic QRS complex in Lead V1 and Lead V2 that is similar to the rSr' configuration seen in RBBB
  • If we look more carefully at Leads V1 and V2 we see 3 mm of J point elevation, followed by a (small and indistinct) r' wave and then a concave upwards down-sloping elevated ST segment that continues into an inverted T wave. This is a typical Type 1 Brugada ECG pattern
  • Lead V3 has a 3 mm J point elevation and a concave upward ST segment that merges into a upright T wave, and is part of the Brugada Type 1 pattern
  • S waves are clearly seen in Leads II and III, and a small S wave is also visible in Lead I. This has been called the "S1S2S3 pattern" - this can be seen in 20 percent of normal individuals (where the S wave amplitude is less than the R wave amplitude) and in right ventricular hypertrophy (where the S wave amplitude often exceeds the R wave amplitude). I do not know if the S1S2S3 pattern is more common in ECGs with a Brugada pattern.

Notes:

1. In 1992, Brugada and Brugada described a new clinical entity characterised by right precordial ST-segment elevation followed by a negative T-wave and a high incidence of ventricular fibrillation in the absence of structural heart disease. It is an inherited heart disease that is thought to be linked to accelerated inactivation of sodium channels in the cardiac cell membrane. The typical ECG anomaly is currently known as the Brugada ECG pattern and the conglomerate of features as the Brugada syndrome.

2. Case 2 had no family history of sudden cardiac death or unexplained episodes of syncope. Case 2 is thus a example of a previously undiagnosed Brugada ECG pattern.

3. Diagnosis of the Brugada ECG pattern depends on recognition of the characteristic changes: an example of Type 1 and Type 2 Brugada ECG patterns is shown in Figure 4 below.

Figure 4 Comparison of the ECG changes in V1 and V2 in Brugada Type 1 and in Brugada Type 2 (J Electrocardiol. 2012; 45: 433–442)

4. A transient Brugada-like ECG pattern may be seen in conditions such as acute ischaemia, pericarditis, myocarditis orpulmonary embolism.

5. A permanent Brugada-like ECG pattern may be seen in RBBB, septal hypertrophy, arrhythmogenic right ventricular dysplasia, athletes or in pectus excavatum

6. Fever can unmask the Brugada ECG pattern and may also trigger ventricular arrhythmias in these patients 

 

References:

Hoogendijk MG, Opthof T,  Postema PG et al. The Brugada ECG pattern: a marker of channelopathy, structural heart disease, or neither ? Toward a unifyingmechanism of the Brugada syndrome. Circ Arrhythm Electrophysiol. 2010; 3:283-290

Bayés de Luna A, Brugada J, Baranchuk A et al. Current electrocardiographic criteria for diagnosis of Brugada pattern: a consensus report. J Electrocardiol. 2012; 45: 433–442

Adler A, Topaz G, Karin Heller K et al. Fever-induced Brugada pattern: How common is it and what does it mean? Heart Rhythm. 2013; 10:1375-1382