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​Lions and Tigers and Bearsby Loice Swisher, MD

Dr. Swisher’s daughter had five episodes of unexplained vomiting without a fever in just one month during 1999. Thinking about those, she said she was unable to shake the memory of a young child she saw in the ED 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? A posterior fossa tumor.

“How did this happen?” she asked the attending, who shrugged and offered up various possibilities. It was a difficult diagnosis because the symptoms at first are nonspecific and 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. "But to an EP, unexplained vomiting is a brain tumor until proven otherwise."

That single phrase altered the course of Dr. Swisher's life​and her daughter's. A "reassurance MRI" showed her daughter had a 5 cm 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 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.

Please share your thoughts about Dr. Swisher's posts.

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Friday, March 1, 2019

LTB-Gissane1.jpg

The distracting arrow could not draw me away from the critical angle of Gissane. Most people think of the Böhler angle when considering calcaneal fractures but not me. The V created by the anterior and posterior facets is what draws my eyes . The comforting V can usually be spotted in nanoseconds. There was only discomfort on this view (and certainly for the patient): The Gissane is missing!

You have to know normal to know abnormal, so here is a comparison.

LTB-Gissane2.jpg

My patient had destroyed her calcaneus. It was obvious. The anterior and posterior facets were not even connected. There was no more Gissane angle!

LTB-Gissane3.jpg

Tip to Remember: Check the critical angle of Gissane and the Böhler angle every single time when looking at the calcaneus.

Friday, February 1, 2019

I grabbed my cell phone to shut off the alarm even before I opened my eyes. As usual on a Sunday morning, I checked the news before my feet left the warmth of the covers so I wouldn't miss a disaster, a tragedy, a loss to remember in the prayers of the day. That day, the first Sunday of Advent, the news of President George H. W. Bush's death led the news. Tears came to my eyes as I read Marshall Ramsey's tribute to the 41st president in The Washington Post. (Dec. 1, 2018; https://wapo.st/2CqDJ8Q.) The cartoonist's tribute showed a TBM Avenger parked in the clouds with Barbara and Robin Bush waiting for his arrival.

I hadn't always known Robin's story. I had been blissfully ignorant of childhood cancer 19 years before, just as George and Barbara Bush had been five and a half decades before. When their second child was diagnosed with advanced leukemia, they had never heard the word. Defying their doctor's recommendations to tell no one and let Robin pass in three weeks or so, the three flew to New York City for the little girl to receive treatment. The hope they had for their blonde-curled preschooler was not to be. The Bush family called Robin's death their greatest sorrow. (The Washington Post. Nov. 30, 2018; https://wapo.st/2CrJkMt.)

On Dec. 3, 1999, I was catapulted into the world of childhood cancer when my then 5-year-old daughter was diagnosed with brain cancer. During that journey, I learned of Robin's story. I connected with the heartaches and hopes of parents of kids with cancer. Times were so different for leukemia then from how it was in 1953. It was because of people like the Bush family who defied the conventional propriety of silence and raised awareness and eventually money that made the difference. When my Tori was diagnosed with brain cancer, the condition had overtaken leukemia as the top cancer killer of kids. In the intervening half-century, childhood acute lymphocytic leukemia was considered likely curable. It was a tough road but curable.

I wasn't a president, or really felt much of anything almost two decades ago. Then again, George was not a president either when his daughter entered that world. I was a doctor. I wondered and hoped that telling our story, would perhaps make a difference even if it was just one.

Checking emails is my second Sunday morning ritual. Unexpectedly, a former resident's name flashed across my screen. He described a preschooler just like my Tori—the unexplained vomiting, the malaise, the horrifically huge posterior mass—and said he thought of our story. He was worried that bringing this up would upset me in some way. It was the opposite. It was a hope realized, that someone remembered and that our story made a difference.

In my follow-up email, I sent him a picture of Tori's tumor and how she looked now. In those early days, it took only one story, one good outcome, one picture of a kid almost two decades later smiling and living life to push back fear a little.

Sitting in church, I held the stories of three parents of children with cancer. As the first Advent candle was lighted, I thought how appropriate that it was hope.

Tip to Remember: Repeated, unexplained vomiting in a child without fever should equal brain tumor until proven otherwise.

My blog post this month is more personal than usual, but another tip to remember is that our stories connect us. These stories are remembered. Some stories hurt, bringing a flow of tears. Others give hope. It isn't always easy to share, but having that vulnerability with each other can make a difference.

LTB-brain tumor.jpg

Monday, December 31, 2018

​It was 6:30 a.m. It should have been easy to dispo the patient with elbow pain by the end of my shift at 7. He had continued pain and swelling, seemingly mostly in the olecranon area. The resident had already put in the x-ray order. A few minutes later, time stopped when I pulled up his lateral.

LTB xray series 1.jpg

 Two decades as a nocturnist without radiology backup for reading plain films has led to my mantras: You have to have a framework to read your x-rays, and my colleagues have to mop up my errors if I don't get this right. It takes time from their patient care, and it makes me look bad.

I have an unwavering stepwise approach with every x-ray series. For elbows, I've incorporated the New York Presbyterian emergency medicine department's approach into my clinical practice. (http://bit.ly/2ra1dZH.)

  1. Hourglass/figure 8
  2. Anterior fat pad evaluation
  3. Posterior fat pad evaluation
  4. Anterior humeral line
  5. Radio-capitellar line
  6. Inspection of the radial head
  7. Distal humerus examination
  8. Olecranon and ulnar examination

Steps 1-4 were completed in seconds in this case. It was with step 5, the radio-capitellar line, where time stood still. The radial head clearly did not articulate with capitellum. It was sitting under it.

LTB xray series 2.jpg

This is an unusual injury. Isolated radial head dislocations are exceedingly uncommon in adults. Radial head dislocations do occur with proximal third ulnar fractures called Monteggia fracture dislocations. This is not that. There is no ulnar fracture.

Without careful attention to the radio-capilletar line, these potentially serious injuries can be easily overlooked with resultant poor range or motion outcomes and significant degenerative arthritis risk. When identified early, these dislocations may be handled with a closed reduction.

Tip to Remember: Have a consistent framework for reading all x-ray series.

Monday, December 3, 2018

TV game shows were all the rage in the '70s. I particularly liked one that had contestants bid against each other on the lowest number of notes they needed to guess a song after the host gave them a clue. Once in a while, one of the players would say, "I can name that tune in one note." Often, they did! I thought they must have known the answer before the piano player struck that one key.

I like to play a similar game with radiographs. Can you name the abnormality in one radiograph with just one clue? Here is the clue: This 9-year-old girl complained of wrist pain after falling on her outstretched right arm.

LTB-buckle fracture 1.jpg

This is what we know:

  • This is trauma, so we are likely looking for a fracture.
  • This is a kid with open growth plates and more plastic bones, so we should be thinking Salter-Harris, buckle, and greenstick.
  • The distal radius is perhaps the most commonly injured area in the wrist in children and adults.

I would take the challenge that I could name that tune in one note, and a quick glance at the distal radius on that one film would tell me I was right. A tiny, subtle bulge on one side and a little angle on the other gives it away. It is like a straw was pushed from end to end, resulting in a buckling indent from the blow. This is a buckle fracture of the distal radius.

Like in the TV show, it is nice to hear the whole song to confirm the answer. These images show the cortical break and angulation definitively.

LTB-buckle fracture 2.jpgLTB-buckle fracture 3.jpg

Tip to Remember: Children have very plastic bones, so buckle fractures may be extremely subtle. When a child complains of joint pain after trauma, take a few extra seconds to look for bulges and angles in the cortex of the long bones, especially where they hurt. And make sure you look at all the views.

Thursday, November 1, 2018

Colleague: Do think that is broken?

Me: Yep.

Colleague: Have you ever seen that before?

Me: No. Still it is broken. How did he do that?

LTB-sesamoid fracture 1.jpg

I've been writing this blog long enough that most people I work with know I love the unusual, unexpected, and even classic radiographs. Most also know that I think emergency medicine is the best of all specialties. There is always a chance of something new, something I have never seen before. We are always learning. Thus, I was drawn in by these radiographs of a patient complaining of pain at the base of his thumb after a motor vehicle crash.

LTB-sesamoid fracture 2.jpg

LTB-sesamoid fracture 3.jpg

LTB-sesamoid fracture 4.jpg

Typically, the hand has re are five sesamoid bones. Two of these likely act as pulleys in the tendons at the thumb's metacarpophalangeal joint. These tiny bones may be fractured by hyperextension of the joint or direct trauma. The photos above magnify the oblique, lateral, and AP images of the base of the thumb. One can easily see the fracture line through the ulnar sesamoid bone in the oblique and lateral views. Often, as in this case, sesamoid fracture is difficult to visualize on the AP film. But look closely, and the typical encircling sclerotic line will appear incomplete. A sharp angle is also seen at the proximal end of the sesamoid bone, which is more common in fractures.

Fortunately, most sesamoid fractures do well with splinting unless there is thumb instability. A few may need surgery for fragments entering the joint or excision for continued pain. Orthopedic follow-up is important to continue to test the integrity of the joint because the lateral joint ligaments and the volar plate may also be injured.

Tips to Remember:

  • These are rare fractures and not infrequently missed. Make sure you assess the tiny sesamoid bones in all views, particularly the sclerotic borders, and look for atypical bony angles.
  • Be aware that joint instability may occur due to ligamentous or volar plate injury. Advise the patient to follow up with orthopedics to reassess the joint.

Suggested Reading:

Becciolini M, Bonacchi G. Fracture of the sesamoid bones of the thumb associated with volar plate injury: Ultrasound diagnosis. J Ultrasound 2015 18(4): 395; http://bit.ly/2ypOZjr.

Fotiadis E, Samoladas E, et al. Ulnar sesamoid's fractures of the thumb: An unusual injury and review of the literature. Hippokratia 2007 11(3):154; http://bit.ly/2R27otL.