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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.

Thursday, December 1, 2016

​A middle-aged man came to the ED for a separate complaint, but his wife was very concerned about his wrist. He said he had injured it several years earlier but never followed up on the injury. Since then, he had been experiencing increasing stiffness and pain. His wife said he could hardly move his wrist. She wanted an x-ray and hoped that something could be done.

LTB-wrist1.jpg

My first thought as the image appeared on the screen was, "That's not normal." It was difficult even to identify where the lunate was. The capitate also seemed to have driven its way down through the proximal row. There was a massive disruption of Gilula's first and second arc lines. This man had scapholunate advanced collapse of the wrist.

In fact, it was significantly advanced. Hand surgeons and radiologists may use the Watson stages to classify the injury and determine treatment:

  • Stage I: Osteoarthritis of the scaphoid and radial styloid articulation
  • Stage II: Osteoarthritis of the entire articular surface of the radius and scaphoid
  • Stage III: Osteoarthritis of lunate and capitate articulation as well as the radius and scaphoid
  • Stage IV: Osteoarthritis of radiocarpal joint with or without involvement of the distal radioulnar joint

This most definitely was at least a stage III.

My next thought was, "What happened before? Do we have x-rays from years ago when he first got his injury?"

LTB-wrist2.jpg

Scapholunate advanced collapse of the wrist is thought to be the most common degenerative arthritis pattern of the wrist. It seems to be most common with nonunion of a scaphoid fracture, or as in this case, untreated scapholunate dissociation. The widening gap between the scaphoid and the lunate was prominent. (Note that this patient appeared to have a congenital fusion of the lunate and triquetrum.)

I strongly advised an appointment with a hand surgeon after showing the patient and his wife the images. I told his wife there are different options, especially surgical ones, to stabilize the wrist. She said she would make sure that he followed up this time.

Tip to Remember: Be vigilant when evaluating for scapholunate disruptions. Untreated, it can lead to wrist collapse.​



Tuesday, November 1, 2016

"I have this older patient who fell on his buttock at home. He has shoulder pain even though he didn't come down on the shoulder, but he was diagnosed with adhesive capsulitis here within the past month. He has x-rays and is going to see the orthopedist this week. I was only going to x-ray the hips. What do you think?"​

"Let me take a look," I said to my resident while pulling up the old images.

LTB 1.jpg

The glenoid fossa was completely obliterated. The bony destruction seemed to have extended as far medially as the coracoid process. The joint space was also impressively widened.

I cautioned the resident to think more broadly when the pain on the exam exceeds the history. This patient could have had a pathologic fracture, metastatic disease, or occult infection; he could have even been the victim of elder abuse. It is also possible for disease to evolve, changing the imaging in just a short time.

LTB 2.jpg

The glenoid fossa was completely obliterated. The bony destruction seemed to have extended as far medially as the coracoid process. The joint space was also impressively widened.

I cautioned the resident to think more broadly when the pain on the exam exceeds the history. This patient could have had a pathologic fracture, metastatic disease, or occult infection; he could have even been the victim of elder abuse. It is also possible for disease to evolve, changing the imaging in just a short time.

 LTB 3.jpg

The diagnosis: new metastatic cancer.​

Tip to Remember: It isn't only fracture that can cause joint pain. Maintain broad thinking especially when the physical doesn't match the history.​


Monday, October 3, 2016

"Hey, I think I can send this guy home with a knee immobilizer, crutches, and ortho follow-up. He hurt his knee when he fell during an altercation. I don't see a fracture on the x-ray. Can I get him out of here?" asked the resident as he documented the x-ray reading.

Glancing at the images, I replied, "Let me look at him because that doesn't look quite right."

The patient was lying in a bed with shorts on, so I could already assess that the knee overall looked relatively normal. No significant effusion, abrasions, or obvious deformity were present.

LTB knee 1.jpg
I asked him to lift his leg off the bed, but he refused. I put my hand two inches above his toe challenging him to try just that far. The leg remained on the stretcher. Next, I lifted his leg with my right hand under the thigh and my left hand under his lower leg. I removed my left hand, and his foot dropped like a rock.

Palpation inferior to the patella toward the tibial tuberosity confirmed my diagnosis. My fingers seems to fall into a hole coming off the lower end of the kneecap. He had a patellar tendon rupture.

Coming back to the resident, I asked what he thought about the patella. Was it high-riding? How could he tell?

LTB knee 2.jpg
Certainly, this wasn't the best lateral. Still, the patella usually articulates directly in front of the condyle, and the distance of the patellar tendon is usually about the same distance as the vertical length of the patella. It was almost twice that far in our patient. A patellar tendon rupture should have been considered on that radiographic basis.

He left with crutches, a knee immobilizer, and orthopedic follow-up but also with awareness that outpatient surgery was in his near future. He had his tendon repaired a week later with good results.

Take-Home Point: Always make sure your knee-injured patients can straight-leg raise, lifting their foot up off the bed. This ensures that the patellar tendon mechanism is intact.


Thursday, September 1, 2016

"This is the best I can do," said the x-ray tech as he pulled me into the room. He added, with some exasperation, "I can't position him because he won't move his wrist."

Defensively, the patient countered, "He doesn't understand. I can't move my wrist."

The images were not what I expected. I had expected to see an obvious fracture. This was a simple case, a FOOSH injury with limited wrist range of motion. The distal radius clinically appeared deformed, prominent, and swollen. He was supposed to have a Colles fracture. I tried to coax more images by promising more pain medicine. With a hint of annoyance in his voice, he reiterated, "Again, it isn't that I don't want to. I can't move my wrist!"

The series was completely inadequate. Maybe a CT. I realized I had no clue what position the patient had to be in to do a wrist CT. The CT tech explained that the patient was traditionally prone with the arms extended overhead and hands palm down. That was impossible. My man couldn't pronate at all. I pleaded for a shot at supine position.

It worked. A half hour later I received a call from the radiologist. The reading: laterally impacted intra-articular fracture of the distal ulna with the impaction against the distal radius and ulnar rotational subluxation. She added, "This is weird. I think you should call the orthopedist."

LTB-DRUJ1.jpgLTB-DRUJ2.jpg 

The 3D reconstruction clearly shows the ulna has slipped out of place palmarly. One should never be able to see both sides of the ulnar notch of the distal radius. The axial images revealed the subluxed, fractured ulna to be caught up on the anterior lip of the ulnar notch.

It was the DRUJ — the distal radioulnar joint! Forearm rotation is controlled by the DRUJ. In fact, when the ulnar head is subluxed volarly, pronation is significantly restricted. The prominent, odd appearance of the distal radius was actually because the companion ulna was not where it was supposed to be.

The patient had been telling me his diagnosis all along. My job was to advocate for him and to convince others that he truly had something wrong. Not long after the orthopedist saw the CT, the wayward ulna was popped back in place in the OR. My guy was discharged with a rotatable wrist later that day.

Take Home Point:
When wrist supination or pronation is limited specifically, consider distal radioulnar joint injury.

LTB-DRUJ CT.jpg


LTB-DRUJ arrows.jpg 

The red arrow points to the radial articular surface of the ulnar notch. The blue arrow shows the subluxed ulnar articular surface for the radioulnar joint, and the yellow arrow points to the impacted ulna at the anterior lip of the radial ulnar notch with several bony fracture fragments.



Monday, August 1, 2016

As this young man found out, it is not wise to ride a bike across trolley tracks at night while intoxicated. It's not shocking that he complained of ankle pain.

ankle 1-2.JPG 

With the deformity apparent, the trimalleolar fracture with lateral dislocation hardly needed an x-ray to tell us where we were headed. The radiology tech documented the devastation while we rounded up the necessary supplies.

I think a four-person team event tends to give the best results: one to give pain medication or sedation and to observe the patient's status, two to splint the leg (one to hold and one to wrap), and one to hold the toes. I always choose the toes. Not only can I watch the patient and the monitor, but I also likely have the best chance at making an awesome reduction.

The ligaments are already shot, so picking up the leg by the toes tends to allow the weight and gravity to bring everything back in place. The great toe needs to be pointed at the ceiling and in line with the patella. Hold the leg by the toes until a sugar tong and a posterior tibial splint are placed.

ankle 3-4.JPG  

Take-Home Points:

  • To get a great reduction, tilt the odds in your favor with enough people to help, and use the weight of the leg to your advantage.
  • Afterwards, don't forget ice, elevation, and neurovascular checks.
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 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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