Letter to the Editor
I had two questions about articles in the April issue.
Jennifer Wiler, MD, wrote about a restrained driver rear-ended at a moderate speed who had a hangman's fracture. (EMN 2012;34:13; http://bit.ly/CarCrash.) Why does she think this is? This is almost unheard of. There must be something about the patient or accident that is unusual. AS? Osteoporosis? Ancient car without proper safety setup? Hit by a bus? I'm intrigued!
James Roberts, MD, wrote about tibial plateau fracture. (EMN 2012; 34:14; http://bit.ly/Tibial.) I've been told you can get a bloody tap from a meniscus but not frankly bloody. Any comments?
Thanks for the great issue. I write for the competition but very much enjoy EMN.
Brady Pregerson, MD
Dr. Wiler responds: Thank you for your inquiry. The patient was petite, and did have a high-riding seatbelt sign on examination near her anterior neck. I don't recall the make and model of the car, but it had no airbags. No doubt an unusual injury for a mechanism that we see often in the ED, but as we know, not all patients read the book, which will always keep us on our toes in the ED.
Dr. Roberts responds: Because the meniscus itself is cartilage and nonvascular, an isolated meniscus tear (usually small and chronic) should not produce blood in pristinely (atraumatically) aspirated joint fluid. Isolated meniscus damage produces clear fluid. An isolated meniscus injury is uncommon in an acute knee injury seen in the ED. Such patients usually present with weeks of pain and disability and then an effusion, not after a significant fall or MVA. Ligamentous injuries do bleed, some profusely. Especially bloody is the anterior cruciate ligament rupture that can cause significant joint hemorrhage, and such an injury should be suspected if a large amount of blood is drained via an acute arthrocentesis.