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, 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.
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?
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."
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.
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.
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.
- 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.
Saturday, July 2, 2016
"What do you think about this VBG from last night?" I asked, thrusting a ribbon of paper at my colleague.
pCO2 47 mm Hg
pO2 59 mm Hg
Na+ 149 mmol/L
K+ 4.2 mmol/L
Cl- 99 mmol/L
Ca++ 1.27 mmol/L
Glu 211 mg/dL
Lac >20.0 mmol/L
tHb 16.3 g/dL
"Was he dead?" he queried.
"What was his anion gap?" came the next question.
"Ethylene glycol? Did you intubate him?" he asked.
That was a great guess, but it was actually PCP and cocaine. The patient, out of control, was TASERed a few times. By the time he got to the ED, though, he was unresponsive, breathing like a freight train, and sweating so much he soaked the sheets. I didn't want to intubate him because he was doing a much better job blowing off his hydrogen ions than I ever could.
I certainly didn't want to make that acidosis any worse. I was surprised his heart could keep beating in the environment he already had. I went with benzos, several liters of fluids, and followed the end-tidal CO2 (which was only 16 on arrival). The gap was down to 21 within 90 minutes with a much improved VBG.
VBG 90 Minutes Later
pCO2 39 mm Hg
pO2 38 mm Hg
Na+ 140 mmol/L
K+ 5.3 mmol/L
Cl- 112 mmol/L
Ca++ 0.95 mmol/L
Glu 94 mg/dL
Lac 8.2 mmol/L
tHb 13.4 g/dL
These previously combative but now "not fighting" patients are the ones that make me worry that they are on the edge of the cliff, potentially crashing at any moment. Perhaps that is because this isn't the first (or second or third) patient I have seen with a pH less than 6.8 from a drug-induced agitated state. Maybe the quiet ones should cause even more angst.
My guy went to the CCU, and his normal CPK was above 10,000 within 12 hours. He did require sedation until the PCP and cocaine wore off. The young human body is remarkably resilient; he was back to his regular life just a few days later.
Take-Home Point: Beware of the unresponsive, previously seriously agitated patient; he may be close to death.
Thursday, June 2, 2016
A young woman came in after a FOOSH injury complaining of difficulty moving a painful shoulder. The Y view was difficult to obtain, but the AP view is below. What three radiographic signs help make the diagnosis?
The signs include:
n The light bulb sign is when the humeral head is rotated internally so it looks more like a lightbulb than a club.
n The rim sign where there is an increased distance (more than 6 mm) between the arc of the glenoid and the arc of the humeral head. The distance is much closer at the top of the glenoid than the bottom in this image.
n There is an angle in Moloney's arch. There should be a smooth scapulohumeral arch. Peaks in the glenohumeral location should raise suspicion of a posterior shoulder dislocation. The equivalent of Moloney's arch in the hip is Shenton line.
This is a posterior dislocation. These account for only two to four percent of shoulder dislocations, and they can look remarkably normal in general location, which means as many as 50 percent have been reported to be missed on initial radiographs. A good Y view can be exceedingly helpful in making the diagnosis.
Request an axillary view or a CT if a Y view is difficult. Bedside ultrasound is likely the quickest way to confirm the diagnosis for those skilled at musculoskeletal point-of-care scanning.
A diagnostic Y view was eventually obtained. The shoulder was put back using a traction-counter traction technique under conscious sedation.
Tips to Remember:
n Careful inspection of the AP shoulder film can increase suspicion for a posterior shoulder dislocation.
n Other imaging modalities are available to confirm the diagnosis.