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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.

Monday, May 2, 2016

"I'm going to get a facial CT on this guy because his eye won't open," the resident said to me as he came out of the patient's room.

Suddenly aware that a lateral canthotomy might be in our immediate future, I asked, "What do you mean? You can't get his eye open? What happened?"

Changing directions, I entered the room to find a surprisingly cooperative patient with a grossly deformed face. The peri-orbital contusion prevented him from voluntarily opening his eye. So is that pre-septal or retro-orbital? We needed to take a look.

Touching the upper lid, the immediate sensation of bubble pop burst forth under my gently retracting fingers. No proptosis or lateral canthotomy now. His vision was normal with no hyphema in the anterior chamber. The extraocular muscle was intact with no entrapment. A lateral subconjuctival hemorrhage likely meant a zygomaticomaxillary complex fracture.

Yep, the red flags of extensive subcutaneous emphysema and a lateral subconjunctival hemorrhage were on the mark. He had a zygomaticomaxillary complex (ZMC) fracture. The arch bar artifact confirmed that our patient was not a novice to trauma.

By whatever name you know ZMC fractures (tripod, tetrapod, malar, or trimalar), these have been thought to be the second most common facial fracture, second only to nasal fractures. These fractures include the zygomatic arch, the inferior and lateral orbital rim, and the anterior walls of the anterior and posterior sinus. Displaced fractures can cause infraorbital numbness and difficulties chewing.

This patient had impressive swelling and multiple fractures, but was discharged on antibiotics and pain medication with the ENT's blessing.

​Tip to Remember: When there is a traumatic lateral subconjunctival hemorrhage, include a zygomaticomaxillary complex fracture on the differential.



Friday, April 1, 2016

A man hobbled into the emergency department complaining of continued ankle pain and increased swelling after falling from a ladder the day before. Ankle images were ordered. The mortis, syndesmosis, and malleoli appeared normal, but the massive medial soft tissue motivated a continued search. Was there something wrong with the lateral talus?

The subsequent CT scan delineated a comminuted fracture of the talar lateral process extending to the subtalar joint — a snowboarder's fracture.

Fractures of the lateral process of the talus are relatively uncommon, frequently missed, and can end up with long-term disability. It has been reported that 15 percent of ankle fractures are related to the lateral process, and missed diagnosis has been initially reported in 40-50 percent of cases. The mechanism of injury is inversion and dorsiflexion, causing the lateral process to be compressed between the distal fibula and the calcaneus. Snowboarders incur this injury approximately 15 times more frequently, and falls and motor vehicle crashes are also implicated in lateral talar process fractures.

Tips to Remember

<​ Maintain a high index of suspicion for a fracture of the lateral process of the talus with ankle sprains.
<​ Consider a CT scan for better visualization of this region if there is concern.
< Caution patients with suspected ankle sprains to seek re-evaluation if not improving as expected in the next one to two weeks.

"Imaging of Fractures of the Lateral Process of the The Talus, A Frequently Missed Diagnosis," Eur J Radiol 2003;47(1):64; http://bit.ly/1oMFgg4.

"Fractures of the Lateral Process of the Talus: Snowboarder's Fracture," Podiatry Institute, 2008; http://bit.ly/1oMFgg4.

Tuesday, March 1, 2016

It's 2 a.m. I glance up from my computer screen where I have been diligently clicking boxes on the EMR to see a 20-something man hobble down the hallway following the nurse to a hallway bed. His left foot had a normal heel strike, but the right always came down on the ball of the foot. Curiosity piqued, I opened a new tab to consider this patient's problem.

The 28-year-old jumped over a fence to get away from a dog, landing on his right heel. He said he had not been able to put pressure on the back of his foot since the injury occurred an hour earlier. It was a pleasure to have something so straightforward.

I checked for an intact Achilles' while I watched for plantar flexion with a squeeze of the calf muscles, and then evaluated for tenderness or defects by directly palpating the tendon. Then I cupped my hand around the heel squeezing in all directions. The directive "don't do that again" virtually confirmed my suspicion that this young man suffered from a calcaneal fracture. I told him as much as I placed the x-ray order.

Seeing the patient wheeled back to his bed,  I popped up the images on PACS.


What? It looked pretty normal. Where was that fracture that had to be there?  There was a small sclerotic line across the tubercle, but that wasn't enough for me make the call.  Sure, I could just treat him like a fracture and hope that he followed up. Still, I really wanted to know. Thinking about the options, I came up with three:

n Send to our out-of-house radiologist for a read, which would incur an expense to the hospital.
n Get a CT scan.
n Send him back for axial calcaneal views.

By choosing the last option, I had no doubt left within minutes. 

Tips to Remember:
n​ Approximately one-third of calcaneal fractures are extra-articular, and thus Böhler's angle and the Critical Angle will be normal.
n If the patient will not walk on the heel and has pain with a compressive grip cupping the heel (medially and laterally), highly consider the possibility of calcaneal fractures.
n​ Special axial images give additional views of the calcaneal tubercle and potentially the sustentaculum tali. ​

Monday, February 1, 2016

I tucked my backpack under the counter as I arrived for my night shift, and a palpable angst descended over my left shoulder. As I started to turn around, I panicked, thinking I'd hear something along the lines of, ""I want you to come now!" Instead, the triage nurse whispered, "Can you see this eyelid laceration I brought back?"


A picture is worth a thousand words, or in this case, just one: Transfer.

Clearly, the blow from a ringed fist caused more damage than our shop without ophthalmology could handle. The medial vertical laceration from orbital rim to orbital rim tearing through both the superior and inferior lacrimal canaliculi alone would be enough to trigger the call. If you stopped the exam at that point, however, you would overlook a red flag of a more significant, eye-threatening injury: bloody chemosis.

Bloody chemosis, also known as a subconjunctival hematoma, is a raised subconjunctival hemorrhage. Bloody chemosis should greatly boost the concern for scleral lacerations, globe rupture, or penetrating foreign bodies. A circumferential subconjunctival hematoma around the cornea should trigger suspicion for blunt globe rupture as well as other ocular injuries.​

Take-Home Point: When you see a raised subconjunctival hemorrhage (bloody chemosis), check the visual acuity, be careful not to put pressure on the globe (no tonometry), place an eye shield, and get an orbital CT.


Monday, January 4, 2016

It was a typical Friday night. A fight breaks out. It all happened fast, and now there's pain. What's wrong with this shoulder?


To figure it out, follow a deliberate sequence: acromion, coracoid, glenoid, borders of the body and spine.


Everything is fine until you get around to the superior border where you find an obvious cortical break and a wide lucency.


Diagnosis: Superior Scapular Fracture



But wait! There's more!


Too often, folks stop looking once their search is satisfied by the fracture. But ligamentous injuries are common companions. Make sure you check the acromioclavicular and the coracoclavicular distance. In this case, the coracoclavicular distance appears concerningly wide. There is almost certainly a significant shoulder separation.


(If you are unsure, compare with the other side.)


Take-home point: Don't be satisfied by your search until you read the entire series of radiographs. If you stop with the first injury, others will be missed.

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 http://www.emedhome.com, 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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