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Lions and Tigers and Bears

Dr. Loice Swisher’s daughter had five episodes of unexplained vomiting without a fever in just one month during 1999. Thinking through the files in her mind, she was unable to shake the memory of a young child with the same complaint 12 years before. The well-looking child had been bounced out of the ED four times with "viral syndrome" and "gastroenteritis." The diagnosis was a posterior fossa tumor.

“How did this happen?” she asked. The attending shrugged, offering up various possibilities. It was a difficult diagnosis because the symptoms at first are nonspecific. It is uncommon. The prior docs probably didn't get her up to walk or look in her eyes. They probably didn't think of it. He concluded, "To an ER doc, unexplained vomiting is a brain tumor until proven otherwise."

That single phrase altered the course of her life. A "reassurance MRI" showed a 5 cm brain cancer, a medulloblastoma. Her daughter navigated a course of radiation, chemotherapy, and multiple complications, and Dr. Swisher started an entirely new medical education in the art of diagnosis.

Amal Mattu, MD, reminds those of us in emergency medicine to be on the lookout for lions and tigers and bears, not horses and zebras, Dr. Swisher explained. As an emergency physician and mother, she knows the profound impact this approach has on a patient's life. Using real cases, this blog aims to expose the lions and tigers and bears out there ready to bite.

Friday, May 01, 2015

Scenario: It's 3 a.m. when a man arrives by EMS with a diffusely swollen, painful ankle, is unable to stand after a fall.


Question: What would the orthopedic consultant find helpful to know about this closed, neurovascularly intact fracture?





Discussion: Virtually every fracture has some kind of classification schema. Distal fibular fractures are no exception. If the orthopedists have gone to all the trouble to have a framework for these fractures, then there must be some important key finding to consider. The emergency physician should have some familiarity with these systems. The Weber classification is easiest to understand because it is based entirely on the anatomic relationship of the fibular fracture to the syndesmosis.


Weber A: Fibular fracture below the syndesmosis.

Weber B: Fibular fracture at the syndesmosis.

Weber C: Fibular fracture above the syndesmosis.


The fibular fracture is above the syndesmosis in this case, and is almost certainly a Weber C. The pronation-external rotation mechanism caused a medial malleolar fracture, a disruption of the anterior and posterior syndesmotic ligaments, and a tear through the interosseous membrane to the level of the fibular fracture. Often Weber C fractures will have widening of the syndesmosis. The more familiar Maisonneuve fracture also could be considered a Weber C.


Answer: This appears to be a Weber C fracture with a spiral fracture of the fibula several centimeters above the syndesmosis and associated with a significantly widened syndesmosis, medial malleolar fracture, and posterior subluxation of the talus.


Resolution: The patient was given pain medication, reduced, splinted, and kept NPO for the OR the next morning.


Tips to Remember:

n Evaluate the level of the distal fibular fractures.

n Assess for widening of the syndesmosis.



Ankle Fractures: Weber and Lauge-Hansen Classification;



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Tuesday, March 31, 2015

Not surprisingly, this x-ray belongs to a patient with severe wrist pain after an accident. A wrist series usually includes four views, but the PA film can be highly revealing with an ordered approach. What abnormalities can you see?



This is my standard approach to reviewing a wrist PA film:

  1. Count the carpals.
  2. Map the gap.
  3. Mark the arcs.
  4. Check the contours.

Here is a step-wise review of this image.

  1. It becomes obvious in counting the carpal bones that the scaphoid is in two pieces and that two fragments are punched off the radial styloid.
  2. A 2 mm or so gap should separate the sclerotic lines outlining the carpal bones. One could think of it like little roads that can be navigated around the carpals. Here, the scaphoid abnormally overlaps the capitate, and the distal fragment is much too close to the radius. In addition, the lunate has a funny tilt, which brings the radial side too close to the capitate.
  3. The proximal and distal carpal rows should be able to be outlined by three gentle arcs, which are called Gilula's arcs. An Internet search is in order if you have never heard of these. Only the third arc of the distal row is intact; the first and second arcs are disrupted.
  4. A careful review of the contours is also called for, and it reveals a step-off of the proximal triquetrum.

Abormalities include:

  • a scaphoid fracture.
  • a radial styloid with two fragments noted.
  • a likely perilunate dislocation given the abnormal positioning of the lunate; a lunate dislocation would give a more triangular appearance.
  • a triquetral fracture.

Tip to Remember:

As William Osler said, "The value of experience is not in seeing much but in seeing wisely." This can be applied to radiograph interpretation when a standard, ordered approach decreases the chances of missing important abnormalities.


Read more about wrist and hand conditions in our archive.


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Monday, March 02, 2015

This guy fell down the stairs, but it happened so fast that he didn't know what exactly happened to injure his wrist. Clearly, it is messed up. What kind of information might the orthopedist want to know?




Distal radius fractures are not uncommon injuries in the emergency department. Many happen after a FOOSH — a fall on an outstretched (usually hyper-extended) hand — resulting in a dorsally displaced radial fracture called a Colles' fracture. This man's injury, however, cannot be a Colles' because the fracture is volarly displaced. It is a Smith's fracture.


I don't like eponyms, though. It is too easy to miscommunicate with others. I believe it is far better to describe the fracture specifically to the consultant.


In this case, the fracture:

  • is volarly angulated.
  • is comminuted.
  • is intra-articular into the radiocarpal joint.
  • is significantly radially shortened, and loss of the radial angle is such that the radial and ulnar styloid are at the same level and the lunate now sits adjacent to the ulna.
  • includes an additional fracture of the ulnar styloid as well as disruption of the radio-ulnar joint.


It is important to know what normal looks like to truly convey what is abnormal. Two points to consider in every distal radius evaluation:


Distal Radial Length: The distal radial length is measured from a point the level of the radioulnar joint to the distal end of the radial styloid. The radial styloid usually extends 11-13 mm beyond the end of the radioulnar joint in the average adult patient.


Distal Radial Ulnar Joint (DRUJ): The articular surface of the ulna and the radius should be smooth without stepoff because the distal ulna sits in the sigmoid notch of the radius. DRUJ disruption is important to recognize because this can be difficult to treat, and unstable injuries may need surgery.


Tips to Remember:

  • Don't use eponyms but rather describe the fracture in detail.
  • With wrist fractures, identify whether there is joint involvement of the radioulnar joint, the radiocarpal joint, or both.


What would be your first step in figuring out how to help this patient?


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Monday, February 02, 2015

And they stick in the mind much longer.


This elderly patient was sent to the ED after an ultrasound for a pulsatile mass. The CT tells the story better than words can. What’s the diagnosis?







The CT showed an 8.6 cm AAA, and the patient underwent endovascular aortic repair (EVAR).


EVAR is performed by deploying a stent across the aneurysm site. The site is usually accessed through the femoral artery. EVAR has significantly decreased peri-operative mortality and morbidity because the patient is not subjected to open repair with clamping of the aorta. In fact, it has been reported that more than half of AAA repairs in the United States are not done via EVAR.


Tip to Remember:

Patients who might not be surgical candidates for an extensive procedure such as open repair of aortic aneurysms may be able to have EVAR.


When was the last time you saw a patient eligible for EVAR in your ED?


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Friday, January 02, 2015

A middle-aged patient recently diagnosed with pneumonia came to the ED with right upper quadrant pain and fullness after a bout of coughing. A CT was obtained because of palpable swelling. What's the diagnosis?




Hernia is one of the first diagnoses that comes to mind with sudden abdominal swelling, but the location was not midline in this case nor was there an incision. A hernia just didn't make sense, so the patient was sent to the Doughnut of Truth: the CT scanner. The images clearly revealed a right rectus sheath hematoma.


Rectus sheath hematomas occur when a tear of the rectus muscle damages the epigastric muscles, causing subsequent bleeding into the sheath. The muscular tear can occur whenever there is sudden, vigorous contraction of the muscle, trauma, or increased intra-abdominal pressure. Pregnancy, coughing, and strenuous abdominal exercises have been associated with rectus sheath hematoma formation. Patients on anticoagulants are more at risk.


Patients who remain stable can be discharged with the recommendations of rest, ice, and pain medications. Some patients may develop an expanding hematoma with hemodynamic instability.


Tip to Remember:

Consider a vascular event when something occurs suddenly.


Did you ever have a patient with a rectus sheath hematoma from a cause other than coughing? Share in the comments section.

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About the Author

Loice Swisher, MD
Loice Swisher, MD, is a clinical associate professor in the Drexel University Emergency Medicine Residency Program in Philadelphia and the first and only female board member of, the educational website. She was graduated from the Medical College of Pennsylvania emergency residency program after an educational fellowship in the early 1990s, and has been the nocturnist in the ED at Mercy Philadelphia Hospital since 1997.

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