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, July 3, 2017

​An elderly woman arrived via ambulance at the emergency department after being knocked to the ground. Right hip pain prevented her from getting up. She had bilateral hip replacements, and was concerned that the right one could have come out of place. The area she indicated didn't seem dislocated. There was range or motion of the hip, and the leg was not shortened. Certainly, x-rays would confirm this.​

LTB hip fracture 1.jpg

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The prostheses were intact. She had neither a hip fracture nor a dislocation. The patient still complained of pain, and was unable to ambulate. On closer inspection, the right superior pubic rami's inferior aspect had a cortical break. It certainly looked different from the other side.​

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CT actually confirmed two fractures of the superior rami.

These fractures are managed nonsurgically, but pubic ramus fractures do not bode well for patients. The reason for this is not clear and likely multifactorial. A study by Hill, et al., found that 13.3 percent of patients who had a fracture of a public ramus died within a year, and 54.4 percent died within five years. (J Bone Joint Surg Br 2001;83[8]:1141.) Certainly, the fracture causes few of these deaths directly. A pubic ramus facture, however, may indicate a frailty, putting the patient at risk. The study also found that simple falls were the most common cause and accounted for 87.4 percent of the fractures.

Tip to Remember: All that hurts in the hip are not proximal femur fractures. Always look at the pubic ring.​

Thursday, June 1, 2017

​A ballplayer had jumped and stretched for the ball but missed. Descending toward the ground, he put out his right hand to protect his face from hitting the pavement. The pain in the hypothenar eminence and lateral wrist was immediate, but he thought he could shake it off. A few hours later, though, he came in with pain in the lateral wrist, difficulty with full supination, inability to bear weight on the ulnar-deviated wrist when placing his hand on the bed and trying to push himself up, and a superficial abrasion on the hypothenar eminence.​



Hypothenar eminence sports injuries are well known to be the cause of pisiform (blue circle) or hook of the hamate (red line) fractures. Two mechanisms are commonly reported — a direct blow or the impact when a loosely held bat (or racket) is kicked back into the palm. He didn't have point palmar tenderness, but I was compelled to look closely at the external oblique — the best view of these carpal bones. I then noticed the sclerotic circle in the hamate on the PA projection, further assuring myself that the base of the hook was intact.



Showing the patient his images, I told him that there was no fracture — not of the pisiform, the hamate, the ulnar styloid, or any other bone. The ulna was snuggled in the radial sigmoid notch just as it should be at the distal radioulnar joint. He blurted out, "That big gap there (blue triangle). Is it supposed to look that way?"

"Yep, but that is exactly where I think the problem is!" I said. "It isn't really a gap." I explained that a cartilage cushion is there, similar to the meniscus of the knee. The cartilage can be crushed or torn, causing pain, swelling, and difficulty moving. That cushion, the triangular fibrocartilage complex (TFCC), makes it difficult to turn the wrist palm up and push up from when pressure is on that side of the wrist. He nodded his head in agreement, and said, "I think that's it."

As he was leaving with his splint and referral to orthopedics, he made a point to see me again. "Thanks, doc, for showing me my x-rays. That really makes sense." It felt like a win for patient care. I'll take that whenever I can.

Tips to Remember: No fracture does not mean no injury. Think TFCC injury if the FOOSH'ed patient has lateral wrist pain, difficulty supinating, and difficulty with weight-bearing on the ulnar-deviated hand.​

Monday, May 1, 2017

I have a passion for interesting x-rays. All of my colleagues know that by now. I'll have just arrived in the ED for my night shift and still be shoving my backpack under the counter when I'll hear a not-so-uncommon comment, "We had a great case today." These stories always energize me. The sharing, the learning, the awesome pickup, the right fight for the patient all remind me of why we do this job.

The signing out doc (knowing my absolute favorite thing is a wrist radiograph) recently popped open some radiographs on the computer, announcing, "You are going to love this."

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I scanned the AP and oblique hand films while he continued, "The patient fell last night and today came in because the hand and wrist were painful and scratched up." He pointed to the webspace between the ring and little finger, and cryptically added, "The odd thing is the patient felt like his knuckle was missing."

Finally I took a stand, "I don't like this little thing here [red arrow], and I don't like that sclerotic line there." Toggling back and forth from AP to oblique, I waffled, "I'm just not sure. It could be OK."

LTB-M lines4.jpg

Grinning while taking control of the mouse, he said, "That was the orthopedist's opinion until I told him to look at the wrist films." On the external oblique, the displaced fragment of the fifth metacarpal base stood out clear as day. He got me.

LTB-M lines3.jpg

Going back to the hand, I knew I had picked up some of the clues. There had to be more there. Something that I had missed or forgotten. And I had.

I had forgotten to look at the parallel M lines. One M line connects all the most proximal sclerotic lines of the carpal bones from the base of the thumb to the little finger. The other M line connects the sclerotic lines at the base of the metacarpals. These two lines are usually only 1-2 mm apart. When focused on these lines, the wide gap at the base of the fifth is glaringly obvious, and the double density increased sclerotic marking at the base of the fourth makes total sense.

I'd momentarily forgotten what normal looked like. The fifth metacarpal base always articulates completely across the top of the hamate. A quick refresher on a normal hand AP would have resolved the question of whether our patient had normal metacarpal-carpal articulation. He did not.

Fortunately, my astute friend had gotten additional views, the patient received appropriate care, and I relearned a valuable lesson.

Tips to Remember: Know normal to pick up the abnormal. Actually look at a normal film if you are unsure. Additional views can add significant perspective.

Friday, March 31, 2017

​A man came to the ED in the middle of the night saying he was jumped and struck on the knee with some object. He complained of severe pain, difficulty ambulating, and swelling. When the tech tried to get the standard series of four knee views, the patient said he couldn't do more than one, at least not without more pain meds. The tech, arms crossed, asked me what I wanted to do. "Do you want to give him more meds, and I'll try again?" he asked.

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Popping the sole image up on the screen, I said, "I'll give him more pain meds because he almost certainly has a tibial plateau fracture. I'm going to send him for a CT." There were a few clues that made me sure that his lateral tibial plateau was broken.

What first jumped out to me was the asymmetry of the distance between the femoral condyle and the tibial plateau. In fact, the lateral femoral condyle even overlapped the tibia. There was no gap. Arthritis can cause joint narrowing, but there were no other signs of that.

Secondly, the sclerotic line of the lateral tibial articular surface was gone. I want both the medial and the lateral articular surface to be "smiling" at me. The concave white line from the tibial spine in the center to the edge of the articular surface was missing laterally. Closer inspection showed an irregularity of the cortex with concern for a cortical break. The irregularity is indicated by the red arrows in the image.

LTB tib plat.jpg

There was a slightly hypodense area inferior to the location of the missing lateral tibial plateau "smile." It is subtle, but if you stand back, your eyes might just pick up that faint circle of white (red circle). This indicates compression of the bone from a depressed fracture.

The CT confirmed my suspicion, and the patient ultimately went into surgery to get a couple of screws to realign the articular surface.

Tip to Remember: When looking at a knee AP after trauma, remember to "mind the gap and smile."

Wednesday, March 1, 2017

​An afebrile diabetic patient came in a week after a drawer was slammed on his hand. He insisted that his hand wasn't broken but hurt much more now than it did when it was initially injured. Do you know the disposition just by looking at the picture?

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I did. It was an Aunt Minnie. I gave him IV antibiotics, admitted him, and arranged a visit to the operating room for him.

The origin of the term Aunt Minnie is somewhat unclear, but it definitely came from radiology. The literature claims that Edward B. D. Neuhauser, MD, a chief radiologist at Boston Children's Hospital, coined this term to mean something so visually distinctive that it can't be anything else. (AJR Am J Roentgenol 2008;191[4]:1272.) Benjamin Felson, MD, later spread the concept in his radiology book, Fundamentals of Chest Roentgenology. (Philadelphia: W.B. Saunders; 1960.)

The idea is that once you have seen something, you know it each time. An Aunt Minnie in my medical training was any disease process that could be immediately perceived. This extends to symptoms from the proptotic eyes in hyperthyroidism to the distinctive rash of Lyme disease.

What makes this an Aunt Minnie?

His hand seemed to be attempting a permanent Vulcan salute with splayed ring and long fingers. One process catapulted to mind, and a volar exam confirmed that I was right.

LTB aunt minnie 2.jpg

This was a collar button abscess, an hour-glass shaped, deep web space infection that spreads dorsally and volarly. The abducted adjacent fingers are the clue not to be missed, indicating more than a superficial infection. Most agree a volar and dorsal incision is required for adequate drainage. (Eplasty 2016;16:ic6.)

This patient did have extensive drainage in the OR. Cultures grew both gram-positive and gram-negative organisms from the "diabetic soup" that the orthopod reportedly encountered.

Tip to Remember: An abnormal position of repose for the hand is always a cause for concern for underlying pathology.​