Knee-chest Position Research Articles

Comparison of Endotracheal Tube Cuff Pressure change between Supine prone and Supine – Knee Chest Position in Lumbar Disc Surgery

Background: In rare instances, massive over inflation of the cuff may lead to acute complications such as tracheal bleeding or rupture. This may be associated with post-operative complications like sore throat hoarseness of voice. The purpose of this study was to evaluate the ETT cuff pressure changes between supine to prone and supine to knee chest position in lumber disc surgery. Materials & Methods: Sixty patients, aged between 18 to 60 years of either sex, belonging to American Society of Anaesthesiology (ASA) physical status I to II undergoing elective lumbar disc surgery under general anaesthesia either in prone position or in knee-chest position were considered for this study. The patients were randomly allocated into two groups of 30 patients each. Group “p” was undergone operation in prone position and group “k” undergone operation in knee-chest position. The patients were connected to standard monitoring system such as non-invasive blood pressure (NIBP), electrocardiogram (ECG), pulse oxymeter, and capnometer. All patients were pre-medicated with inj. glycopyrrolate 0.2 mg and inj. fentanyl 2µg/kg iv 5-6 minutes before induction of anaesthesia and were pre-oxygenated with 100% oxygen for atleast 3 minutes. All the patients were induced with inj. propofol 2.5 mg/kg i.v. followed by inj. rocuronium at a dose of 1.2 mg/kg for facilitating tracheal intubation with reinforced ETT. The ETT size selected for men and women were 8.0-8.5 mm ID and 7.0- 7.5 mm ID (Mallinckrodt) respectively. Results: Group k patients showed higher cuff pressure change from 25 to 39.97cm of H2O compared to group p from 25 to 30.47 cm of H2O after change of position only. There was statistically significant different found between groups Sore throat was found significantly higher in group k compared to group p (20% vs 16.67%). Conclusion: The cuff pressure of the endotracheal tube should be monitored and managed properly after the position change from supine to prone and prone to knee chest position.

A case of complex asphyxia sheds light on problems in the classification of asphyxias

Death from positional asphyxia is often an accidental event occurring when the victim’s body assumes a position which can compromise an effective respiration. Its diagnosis is usually not simple, because it needs to know the exact circumstance in which the body was found and the original positioning of all the body segments. In this case, a 41-year-old man with a history of opioid drugs abuse was found dead in a knee-chest position; the head was down on the floor with the face resting on a plastic bag. Pictures of the scene of death was taken while the body was still in its original position. At first, the main suspicion was that of a fatal overdose. Following the autopsy examination, completed by histological and toxicological examinations, the cause of death was determined as postural asphyxia secondary to intoxication by methadone, in the presence of ischemic heart disease. Some features, moreover, were typical of the death in head down position, and the prolonged knee-chest position was also associated with the obstruction of mouth and nose by the plastic bag, which may have contributed to the asphyxiation. These cases of “combined” asphyxia represent a challenge for the current classifications of asphyxia, which are very variable and not standardized, as we observe from a brief review of the literature. The elaboration of new systems of classification for asphyxias, which must be clear, simple and shareable, is necessary to avoid confusion in categorizing cases that present overlapping between several types of asphyxiation modalities.

Efficacy of Fenestration Technique for Lumbar Disc Excision in Pain Relief

Objective: To determine the outcomes of lumbar disc excision by fenestration technique for pain relief in lumbar radiculopathy due to prolapsed intervertebral disc. Methodology: This is a descriptive study conducted in a joint venture of orthopedic and neurosurgeons in a private hospital of Lahore. Study was completed in six months duration from July to December 2022. All patients presenting with lower back pain, straight leg raise test positive on <60 degrees and prolapsed disc at the level of L4/L5 or L5/S1 L discs on MRI. Those with multilevel disc prolapse, previous history of spinal surgery, cauda equine syndrome and patients with lumbar stenosis were excluded from the study. All study patients were operated under general anesthesia in knee chest position. Efficacy of the procedure was determined using Dennis Pain Scale. Important findings were documented when patient was discharged. SPSS version 20 was used for statistical analysis. Results: 125 patients were studied including 73(58.4%) males and 52(41.6%) females. Patients with the age of 20-60 years were included in this study with the mean age of 47.3 ± 5.2 years. Most commonly involved disc level was L4-L5 in 77(61.6%) and L5-S1 in 48(38.4%) cases. Unilateral radicular pain was present in 94(75.2%) cases and bilateral pain was present in 31(24.8%) cases. According to Dennis Pain Scale out of 125 cases 78(62.4%) patients presented in Dennis pain scale P4 and among them complete recovery achieved in 70(89.7%) cases. Conclusion: Surgical intervention is necessary in selected patients with prolapsed intervertebral disc with chronic unilateral or bilateral radicular pain. Fenestration technique for disc excision is a very good procedure for prolapsed disc. Keywords: Sciatica, Disc Excision, Prolapsed Disc, Radiculopathy

The Impact of Maternal Position in Labor on Occiput-Posterior Position of Fetus and Pregnancy Outcomes in Pregnant Women Without Epidural Analgesia.

Fetal occiput posterior (OP) position is associated with more maternal and neonatal complications. This study aimed to investigate the effect of maternal position during labor on fetal OP position and pregnancy outcomes. This randomized clinical trial study included 180 primigravida women in labor with a single fetus and approved OP position. Participants were randomly allocated into three groups: semi-prone position (n=45), knee-chest position (n=45), and supine position (n=90). All participants were placed in the defined positions 15-30 min in labor until delivery. Data collected using Visual Analogue Scale and researcher made checklist. The ANOVA, Tukey post hoc, and the chi-square test were used to analyze. Among all participants who had OP, after intervention 16.3% in the semi-prone position, 14/3 % in the knee-chest position, and 33.7% of the control groups remained with OP at birth (X3=7/87, P=0.019). The rate of natural delivery was significantly higher in the semi-prone position and knee-chest position. The duration of active phase of labor and low back pain were significantly reduced in the semi-prone and knee-chest position compared to the control groups (P<0.05). There were no differences in the duration of the third stage of labor, APGAR score, and the rate of neonatal addition to neonatal intensive care unit, using oxytocin, and perineal tears (P>0.05). The semi-prone and knee-chest positions increase the spontaneous rotation of occiput to the anterior position, vaginal delivery rates as well as a reduction in duration of active phase of labor and low back pain after delivery.

Faktor yang Berhubungan dengan Upaya Penanganan Keluhan Dismenore pada Siswi SMK Negeri 17 Samarinda

Dysmenorrhea are still quite high but there are still few young women who seek information about dysmenorrhea and the impact it causes. This triggers young women to pay less attention to the handling efforts made when experiencing complaints of menstrual pain. This study aims to find out the relationship between knowledge, the degree of pain and exposure to information with efforts to handle dysmenorrhea complaints. This type of research is quantitative with a cross sectional approach. The study population was 425 with a sample of 197 people using purposive sampling techniques. The data was taken using questionnaires. Analysis of the data used using the Spearman Rank Test with a 95% confidence level. The results showed that respondents' handling efforts were in the good category (39.6%), respondents' knowledge levels were in the good category (58.4%), respondents' pain levels were in the category of mild pain (58.9%) and the respondent information exposure category was in the exposure category (61.9%). The study's conclusions showed there was a relationship between knowledge (p-value 0.000), degree of pain (p-value 0.035) and exposure to information (p-value 0.049) with efforts to handle dismenore complaints. It is recommended to be able to increase socialization evenly to all students so that each student gets the same information in addition to it is recommended that students can improve handling such as exercising, doing knee chest positions and doing examinations to the doctor and maximizing parental support as an accurate source of information

A holistic approach for severe flexion contracture of bilateral hip, knee, and ankle joints in a neglected patient with prolonged knee–chest positioning on extreme undernourishment: a case report and review of the literature

BackgroundFlexion contracture in the lower extremity is a common finding in the patient with neuromusculoskeletal disorders. However, severe cases due to prolonged immobilization in knee–chest position are rarely established and remain underreported. This condition is associated with high morbidity and reduced quality of life, especially when it comes to neglected cases with missed injury and late presentation for adequate primary care and rehabilitative program. It remains a difficult challenge to treat, with no established treatment protocol. In addition, other factors related to psychological and socioeconomic conditions may interfere and aggravate the health state of such patients.Case presentationA 19-year-old Javanese man presented with flexion contracture of bilateral hip, knee, and ankle joints due to prolonged immobilization in knee–chest position for almost 2 years following a traffic accident and falling in the bathroom. The condition had persisted for the last 3 years due to irrecoverable condition and lack of awareness. In addition, the patient also presented with paraplegia at level L2–S1, dermatitis neglecta, multiple pressure ulcers, community-acquired pneumonia, and severe malnutrition. Prolonged and sustained passive stretching with serial plastering were performed in the patient. By the time of discharge, patient was able to move and ambulate using wheelchair. Progressive improvement of range of motion and good sitting balance were observed by 3-month follow-up.ConclusionA combination of surgery and rehabilitative care is required in the setting of severe flexion contracture. Passive prolonged stretching showed a better outcome and efficacy in the management of flexion contracture, whether the patient undergoes surgery or not. However, evaluation of residual muscle strength, changes in bone density and characteristic, and the patient’s general and comorbid conditions must always be considered when determining the best treatment of choice for each patient to achieve good outcome and result. A holistic approach with comprehensive assessment is important when treating such patients.

Onset Time of Spinal Anaesthesia in Pregnant Females in Knee-Chest Position: A Randomized Controlled Study

ObjectiveTo assess the efficacy of knee-chest position in shortening the time of spinal induction in pregnant women undergoing elective cesarean section. We also assessed for any untoward adverse events that might limit their usefulness in real-life clinical scenarios.MethodsProspective, randomized controlled study was done in maternity operating room of tertiary care institution in 45 ASA II pregnant women undergoing elective cesarean section under spinal anaesthesia. Patients were randomly assigned to groups S (supine) and K (knee-chest position). After performing subarachnoid block (9 mg of 0.5% hyperbaric bupivacaine and 25 µg fentanyl) in the sitting position, women in group K were maintained in the knee-chest position for 60 seconds. Time to attain block height of T6 and maximum sensory blockade, intraoperative hemodynamics, Bromage score, intraoperative fluid, vasopressor requirement, and respiratory parameters were recorded. The newborn was evaluated using Apgar scores at 1 and 5 minutes.Results: Data of 45 patients were analyzed. Time to attain T6 block height (group K = 2.1 ± 0.65 minutes, 95% CI: 1.83-2.39; group S = 6.4 ± 0.77 minutes, 95% CI: 6.10-6.78) and time to achieve maximum sensory block height were significantly lower in group K (group K = 3.2 ± 1.35 minutes, 95% CI: 2.61-3.78; group S = 6.6 ± 0.89 min, CI: 6.19-6.98). The degree of motor block was higher in group K than that of group S at 2 minutes (P = .0002), 4 minutes (P < .0001), and 6 minutes (P < .0001), with no difference at 8 minutes. No statistically significant difference was observed in fluids and vasopressors requirement intraoperatively.ConclusionsThis study provides evidence that the onset of adequate surgical anaesthesia for the cesarean section can be hastened by placing the patient in the knee-chest position for a minute after performing the subarachnoid block in the sitting position.

Surgical management of lumbar spinal stenosis in patients over 80: is there an increased risk?

Management of lumbar spinal stenosis (LSS) represents the first cause of spinal surgery for the elderly and will increase with the aging population. Although the surgery improves quality of life, the procedure involves anaesthetic and operative risks. The aim of this study was to assess whether the postoperative complication rate was higher for elderly patients and to find confounding factors. We conducted a retrospective study including all LSS surgeries between 2012 and 2020 at the University Hospital of Caen. We compared two populations opposing patients aged over 80 with others. The primary endpoint was the occurrence of a severe complication (SC). Minor complications were the secondary endpoint. Comorbidities, history of lumbar spine surgery and surgical characteristics were recorded. Nine hundred ninety-six patients undergoing surgery for degenerative LSS were identified. Patients over 80 were significantly affected by additional comorbidities: hypertension, heart diseases, higher age-adjusted comorbidity Charlson score, ASA score and use of anticoagulants. Knee-chest position was preferred for younger patients. Older patients underwent a more extensive decompression and had more incidental durotomies. Of the patients, 5.2% presented SC. Age over 80 did not appear to be a significant risk factor for SC, but minor complications increased. Multivariate analysis showed that heart diseases, history of laminectomy, AA-CCI and accidental durotomies were independent risk factors for SC. Surgical management for lumbar spinal stenosis is not associated to a higher rate of severe complications for patients over 80years of age. However, preoperative risk factors should be investigated to warn the elderly patients that the complication risk is increased although an optimal preparation is the way to avoid them.

Cephalic version by postural management in the lateral position without the knee-chest position for primiparous breech presentation: A retrospective cohort study.

This study aimed to determine the efficacy of postural management in the lateral position for primiparous breech presentation. A retrospective cohort study was conducted at a single institution from January 2020 through December 2020. Participants were singleton primiparous pregnant women diagnosed with breech presentation between 28 + 0 and 29 + 6 weeks of gestation. The exclusion criteria were scheduled cesarean delivery, uterine malformation, transverse position, and scheduled delivery at another hospital. A doctor instructed the women in the intervention group to lie on their right sides several times a day if the fetal back was on the left side or lie on their left sides if the fetal back was on the right side. The knee-chest position and other methods were not recommended. The control group received expectant management care. The primary endpoint was the percentage of fetuses in a cephalic presentation 2 weeks later. Of the 56 women included in the study, 17 women were instructed to lie in the lateral position, and 39 women received expectant management care only. After 2 weeks, women who were instructed to lie in lateral position had a higher rate of fetal cephalic version than the control group (82.4% [14/17] vs. 43.6% [17/39], p=0.017). No study participants experienced adverse effects. Two weeks of postural management in the lateral position without the knee-chest position significantly reduced the rate of primiparous breech presentation in the third trimester of pregnancy.

Effect of knee-chest, semi-sitting, and right lateral position on preterm neonates with respiratory distress syndrome

Effect of knee-chest, semi-sitting, and right lateral position on preterm neonates with respiratory distress syndrome

Transperineal ultrasound assessment of fetal head elevation by maneuvers used for managing umbilical cord prolapse.

To assess objectively the degree of fetal head elevation achieved by different maneuvers commonly used for managing umbilical cord prolapse. This was a prospective observational study of pregnant women at term before elective Cesarean delivery. A baseline assessment of fetal head station was performed with the woman in the supine position, using transperineal ultrasound for measuring the parasagittal angle of progression (psAOP), head-symphysis distance (HSD) and head-perineum distance (HPD). The ultrasonographic measurements of fetal head station were repeated during different maneuvers, including elevation of the maternal buttocks using a wedge, knee-chest position, Trendelenburg position with a 15° tilt and filling the maternal urinary bladder with 100 mL, 300 mL and 500 mL of normal saline. The measurements obtained during the maneuvers were compared with the baseline measurements. Twenty pregnant women scheduled for elective Cesarean section at term were included in the study. When compared with baseline (median psAOP, 103.6°), the knee-chest position gave the strongest elevation effect, with the greatest reduction in psAOP (psAOP, 80.7°; P < 0.001), followed by filling the bladder with 500 mL (psAOP, 89.9°; P < 0.001) and 300 mL (psAOP, 94.4°; P < 0.001) of normal saline. Filling the maternal bladder with 100 mL of normal saline (psAOP, 96.1°; P = 0.001), the Trendelenburg position (psAOP, 96.8°; P = 0.014) and elevating the maternal buttocks (psAOP, 98.3°; P = 0.033) gave modest elevation effects. Similar findings were reported for HSD and HPD. The fetal head elevation effects of the knee-chest position, Trendelenburg position and elevation of the maternal buttocks were independent of the initial fetal head station, but that of bladder filling was greater when the initial head station was low. To elevate the fetal presenting part, the knee-chest position provides the best effect, followed by filling the maternal urinary bladder with 500 mL then 300 mL of fluid, respectively. Filling the bladder with 100 mL of fluid, the Trendelenburg position and elevation of the maternal buttocks have modest effects. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Quando lo squat fa la differenza

The paper presents the case of a 1-year-old girl with severe respiratory distress, perioral cyanosis and severe desaturation (SpO2 35% with oxygen in nasal prongs). An echocardiogram was readily performed showing the distinctive features of Fallot’s tetralogy. The child was placed in a squatting position (knee-chest position). Subcutaneous morphine at a dose of 0.2 mg/kg, bolus of physiological solution in 30 minutes and therapy with oral propanolol were administered, with progressive clinical improvement. Subsequently, corrective cardiac surgery was performed with regular postoperative period and following good clinical conditions. Cardiogenic causes must be considered among the causes of respiratory distress especially in low resource countries where congenital heart disease can be misdiagnosed or diagnosed belatedly.

Repositioning the Fetal Breech Location with Settings Knee Chest Position and Yoga Practice for Pregnant Women

Presentation or location of breeders may threaten the life of both the mother and the fetus. The condition of the uterine fundus is longitudinal, indicated by the shape of the uterus and the lack of space for fetal growth in the uterus. The up chest position Settings and the practice of yoga with certain positions on the expectant mother still did little research even though it repositioned the fetus into normal conditions. The purpose of the study is to find out the relationship of the knee-chest and the pose of yoga adho mukha svanasana to the reposition of sungsang on pregnant mother trimester iii, the liberating respondents count 88 in the two groups that get treatment of the knee-chest and adho mukha svanasana the study uses a quantitative approach with a test of chi-square to measure the significance of the independent relationship. It has found a link between the knee-chest position and the yoga pose adho mukha svanasana to the fetal reposition on pregnant mother trimester iii. The critical conclusion for health workers is to socialize expectant mothers to perform regular checkups to know the fetus’s condition in the womb. If not for a handler to reposition the baby would be a risk of troubled delivery.

Effect of Hemodynamic Changes in Plasma Propofol Concentrations Associated with Knee-Chest Position in Spinal Surgery: A Prospective Study.

BackgroundAnesthesia induction and maintenance with propofol can be guided by target-controlled infusion (TCI) systems using pharmacokinetic (Pk) models. Physiological variables, such as changes in cardiac output (CO), can influence propofol pharmacokinetics. Knee-chest (KC) surgical positioning can result in CO changes.ObjectivesThis study aimed to evaluate the relationship between propofol plasma concentration prediction and CO changes after induction and KC positioning.MethodsThis two-phase prospective cohort study included 20 patients scheduled for spinal surgery. Two different TCI anesthesia protocols were administered after induction. In phase I (n = 9), the loss of consciousness (LOC) concentration was set as the propofol target concentration and CO changes following induction and KC positioning were quantified. In phase II (n = 11), based on data from phase I, two reductions in the propofol target concentration on the pump were applied after LOC and before KC positioning. Propofol plasma concentrations were measured at different moments in both phases: after induction and after KC positioning.ResultsSchnider Pk model showed a good performance in predicting propofol concentration after induction; however, after KC positioning, when a significant drop in CO occurred, the measured propofol concentrations were markedly underestimated. Intended reductions in the propofol target concentration did not attenuate HD changes. In the KC position, there was no correlation between the propofol concentration estimated by the Pk model and the measured concentration in plasma, as the latter was much higher (P = 0.013) while CO and BIS decreased significantly (P < 0.001 and P = 0.004, respectively).ConclusionsOur study showed that the measured propofol plasma concentrations during the KC position were significantly underestimated by the Schnider Pk model and were associated with significant CO decrease. When placing patients in the KC position, anesthesiologists must be aware of pharmacokinetic changes and, in addition to standard monitoring, the use of depth of anesthesia and cardiac output monitors may be considered in high-risk patients.

Hemodynamic Changes and Propofol Pharmacokinetic Variation During Anesthesia Induction and Knee-chest Positioning

Hemodynamic Changes and Propofol Pharmacokinetic Variation During Anesthesia Induction and Knee-chest Positioning

Case series: review of several types fistulas of anorectal malformation on distal loopography

Introduction: Anorectal malformation (ARM) is a wide spectrum of congenital malformations involving the distal rectum and anus as well as the urinary and/or gynaecological systems with an estimated incidence ranging between 1 in 2000 and 1 in 5000 live. Types of fistulas are essential to diagnose to decide the management and surgical repair. We review several fistula types of anorectal malformation based on distal loopography examination. Case Presentation: Review of 5 patients with distal loopography in Sanglah Hospital was performed. All patients were neonate with absence of the anus without any clues of fistulas.  Plain abdominal x-ray and knee-chest position showed distended loops of bowel and blind-ending of distal rectum with various distance from anal dimple. Two cases were confirmed as high type of ARM with recto-vesica fistula, where the contrast filled rectum and the bladder which decreased significantly after micturition. The two other cases were confirmed as high type ARM with recto-urethrae fistula, and the last one as low type of ARM with recto-perineal fistula. All patients undergoing surgical management for fistula repair and anorectal reconstruction.Discussion: Anorectal malformation forms a heterogeneous group of anomalies, most cases showed imperforated anus and blind-ending of distal enteric component (atresia) with or without fistula. Our cases were diagnosed by plain x-ray and contrast study. High or low type was evaluated from the distance rectal pouch to anal dimple. Distal loopogram was showed low type of ARM with recto-perineal fistula and high type of ARM with fistula extended anteriorly as recto-vesica fistula and recto-urethrae fistula, as The Krickenbeck classifications.Conclusion: Distal loopography is an important diagnostic investigation to delineate the altered anatomy of anorectal malformations, the location fistula and the spectrum of associated fistula between the blind rectum and the bladder, urethra, perineum, scrotal and vagina. Radiology interpretation is indeed important for clinician to establish patient management.Â

Propofol TCI Reductions Do Not Attenuate Significant Falls in Cardiac Output Associated With Anesthesia Induction and Knee-Chest Positioning in Spinal Surgery.

Induction of anesthesia and the knee-chest position are associated with hemodynamic changes that may impact patient outcomes. The aim of this study was to assess whether planned reductions in target-controlled infusion propofol concentrations attenuate the hemodynamic changes associated with anesthesia induction and knee-chest position. A total of 20 patients scheduled for elective lumbar spinal surgery in the knee-chest position were included. In addition to standard anesthesia monitoring, bispectral index and noninvasive cardiac output (CO) monitoring were undertaken. The study was carried out in 2 parts. In phase 1, target-controlled infusion propofol anesthesia was adjusted to maintain BIS 40 to 60. In phase 2, there were 2 planned reductions in propofol target concentration: (1) immediately after loss of consciousness-reduction calculated using a predefined formula, and (2) before positioning-reduction equal to the average percentage decrease in CO after knee-chest position in phase 1. Changes from baseline in CO and other hemodynamic variables following induction of anesthesia and knee-chest positioning were compared. Induction of anesthesia led to decreases of 25.6% and 19.8% in CO from baseline in phases 1 and 2, respectively (P<0.01). Knee-chest positioning resulted in a further decrease such that the total in CO reduction from baseline to 10 minutes after positioning was 38.4% and 46.9% in phases 1 and 2, respectively (P<0.01). There was no difference in CO changes between phases 1 and 2, despite the planned reductions in propofol during phase 2. There was no significant correlation between changes in CO and mean arterial pressure. Planned reductions in propofol concentration do not attenuate anesthesia induction and knee-chest position-related decreases in CO. The knee-chest position is an independent risk factor for decrease in CO. Minimally invasive CO monitors may aid in the detection of clinically relevant hemodynamic changes and guide management in anesthetized patients in the knee-chest position.

Importance and Significance of Knee-Chest Decubitus Position of the Pregnant Women, in the Delineation of Fetal Facial Imaging with Four-Dimensional Color Doppler Ultrasound

Objective: To investigate and validate the role of the Knee-chest Decubitus position in fetal facial feature delineation by 4D Ultrasonography. Methods: Pregnant women were randomly divided into two groups: One group underwent knee-chest decubitus position prior to re-examination, and the second group underwent free activities like walking for 5, 15 or 30 minutes followed by a re-examination of the fetus. The acceptability of the fetal facial images following the two above mentioned activities was compared. Results: The Knee-chest Decubitus position was identified to be a more successful procedure for obtaining acceptable images. Additionally, it improved the fetal position and the resulting images were achieved significantly rapidly by this maneuver compared to free movement. Conclusion: The knee-chest decubitus position is simple, easy, safe and fast and thus of great convenience and promising for pregnant women.

Coccygeal excision for treatment of coccyx instability

Introduction: Coccygeal excision or coccygectomy is a rare procedure for the treatment of coccygodynia. Coccygeal pain or coccygodynia, often successfully treated with conservative treatment, including steroid injection. In coccyx instability with persistent pain after failed with conservative and injection treatment, surgery is needed to remove the unstable tail bone segment. Methods: We present one case of persistent coccygeal pain in a twenty-five year old male. The patient had a history of trauma on the buttock 12 years ago, which is getting worse for the last one-year period. The patient has already undergone conservative treatment, including two episodes of steroid injection, but the pain still persists. From the lateral plain X-ray, it was found displacement on coccyx segment. Failed in conservative treatment leads to coccygeal excision. The surgical procedure was done in prone knee-chest position, and intraoperatively assessed the tailbone stability with image intensifier. Partial coccygectomy was done to this patient. Results: One month follow up showed painless tailbone, no surgical site infection, and no other complications. Conclusion: We conclude that coccygeal excision is a good treatment of choice for coccygodynia due to coccyx instability.

Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients

BackgroundPrepubertal genital bleeding can be caused by a variety of etiologies including trauma, infection, structural, hematologic disorders, precocious puberty, and malignancy. Urethral prolapse can be seen in prepubescent girls due to a relative estrogen deficiency. Urethral prolapse classically presents with urethral mass and vaginal bleeding, often associated with constipation. Case ReportA healthy 6-year-old White girl presented to the Pediatric Emergency Department (ED) with vaginal bleeding for 1 day preceded by a few months of constipation. In the ED the patient's physical examination was remarkable for a tender, nonmobile mass at the vaginal introitus. Transabdominal pelvic and renal ultrasounds were unremarkable. The emergency physician's working diagnosis was a vaginal mass concerning for sarcoma botryoides. Pediatric and Adolescent Gynecology (PAG) was consulted. They performed an examination under anesthesia (EUA) with cystoscopy and vaginoscopy. The EUA confirmed a urethral prolapse approximately 2 cm in diameter. The patient was treated with conjugated estrogen vaginal cream. At her 1-month follow-up, the urethral prolapse had resolved. Why Should an Emergency Physician Be Aware of This?Performing a proper pelvic examination of a prepubescent girl presenting with vulvovaginal bleeding is crucial to form an accurate diagnosis in the ED setting. By placing the young girl in the frog-leg or knee-chest position and using both lateral and downward traction of the vulva, one can adequately visualize the external genitalia and outer 1/3 of the vagina. This can help streamline diagnosis and avoid unnecessary examinations and anxiety.