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​Lions and Tigers and Bears​ by 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, May 1, 2020

Pain from an Unknown Cause

​"My left hip has been hurting for a couple years, but it just got really bad in the past few weeks."

My patient, who was in her 70s, didn't add much more to the history. No trauma. No fevers. No bowel or bladder problems. No significant past medical history. Her hip just hurt. She thought she needed an x-ray, and one was obtained.

LTB-x-ray-hip-pain-cancer.jpg

The left femoral head didn't look terrible. There was some irregularity, but there were no fractures or significant joint narrowing. This wasn't a case of neglected severe degenerative joint disease or avascular necrosis that needed a hip replacement.

Some red flags started to show up toward the left iliac bone. The trabecular pattern was just not right. It wasn't uniform in lines or density. The cortex had discontinuous areas. Clearly, it didn't look like the other side. She didn't have a history of cancer, but this bony destruction could certainly be a metastatic neoplastic disease.

LTB-x-ray-iliac bone-trabecular pattern-cortex-bony destruction.jpg

The next step, a noncontrast pelvic CT, clearly showed the malignant disruption of the bone. She was admitted for pain control and to initiate her metastatic cancer workup to define the extent of the disease of unknown primary.

Tip to Remember

  • The elderly patient with unremitting pain may have cancer in her bones. Sometimes this is the presenting complaint for a cancer diagnosis.
  • When one is unsure of hip or bony pelvis pathology, a noncontrast CT scan can assist with defining the path.

Wednesday, April 1, 2020

Watch This Space

​I am relatively new to working with our advanced practice practitioners, so I often check x-rays if I have a moment.

An x-ray of a wrist has a great chance of being reviewed because this is my favorite joint. I love the challenge of catching things when I don't know the case. I was definitely rewarded by this case.

LTB-wrist xray-scaphoid-lunate.jpg

The thing that caught my eye was the space between the scaphoid and the lunate. It was huge, especially when looking at the sclerotic changes in the other bones of this wrist. Most of the joint spaces seem narrowed but not the scapholunate. Whether you go with the British version (Terry Thomas) or the American (David Letterman), that gap is a problem.

Over time, the capitate can drive down like a wedge between the lunate and the scaphoid, causing a debilitating scapholunate advanced collapse, also known as a SLAC wrist. Pain, surgery, and loss of function are likely in the future of a patient who does not have this fixed. This is an injury not to be missed.

Tip to Remember: Mind the gap in the wrist, particularly between the scaphoid and the lunate.

Monday, March 2, 2020

Not Alone

​"Hey, what do you think of this? It isn't dislocated, but this guy was in a fight, and has a lot of shoulder pain," a colleague said to me.

LTB-humerus-x-ray-shoulder injury-coracoid-acromion.jpg

It seems that the humerus gets virtually all the attention in shoulder x-rays, particularly in the Y view. Many are done with the image after determining the head truly sits in the middle of the Y between the coracoid and the acromion. There is more to shoulder films than just the humeral head's location, however. Take another look at the coracoid and the acromion.

Scapular fractures account for just one percent of fractures. The vast majority of these are of the body and the neck. Coracoid fractures make up just more than 10 percent of all scapular fractures. Although rare, these are not to be missed because they almost never occur alone. One should also look for AC separations, glenoid injuries, rotator cuff tears, and fractures of the acromion or lateral clavicle. AC separations are most commonly associated with coracoid fracture.

Orthopedists may also refer to the coracoid as the lighthouse of the shoulder. It actually looks sort of like a lighthouse. This structure marks where the neurovascular bundles travel nearby. Of note, it anchors multiple tendons and ligaments. Fractures of this tiny structure may shine a light on many more problems the patient could have.

The CT confirmed those initial concerning lucent lines at the coracoid base and the acromion. Both were broken. As is the general rule, the coracoid often does not break alone.

LTB-shoulder injury-coracoid fracture-acromion.jpg

Tip to Remember: Take a moment to palpate under the distal clavicle when a patient has a shoulder injury. One can feel the fullness of the humeral head with dislocations. Significant tenderness may also be a tip-off to take a second look at the coracoid process. If it is fractured, remember that it rarely travels alone.

Friday, January 31, 2020

Air with Nowhere to Go

​I have been writing this blog for nearly six years, and my curiosity and pleasure in reviewing interesting, unusual radiographs are widely known among my colleagues. On a recent shift, a friend brightened on seeing me and exclaimed, "I want you to take a look at this!" She immediately opened PACS to this image.

LTB-xray-radiograph-fall-shoulder injury-air in lungs.jpg

"What's the story?"

"An elderly lady had a mechanical fall at home, coming down on her right shoulder."

"What do you think?" I asked, glancing at my med student.

"The joint looks too close. There is a lot of DJD. I can't tell if there is a fracture."

"Yes, but look at the whole image, not just the joint. Look for something that isn't supposed to be there," I said.

He pointed at the irregular blackened area. "This here, it is black. Is it air? Why's that there?"

That is the question: Why is air there? It would seem most likely from an injury to the lung, although air can track down the neck from facial and upper airway injuries. It is also possible for air to track upward from a pneumoperitoneum. The thorax would seem to be the most likely culprit in this case, however, with the air seemingly centered around the body of the scapula.

"And the noncontrast CT showing a pneumothorax is next up?" I asked my colleague.

 LTB-CT-fall-air-chest wall-lung puncture.jpg

Air was clearly dissecting its way along the chest wall muscles, traveling anteriorly under the scapula and down the body. The perpetrator of this abnormality almost certainly was the minimally displaced rib fracture (arrow), puncturing the lung underneath. The air seemed to bubble up initially from there. Surprisingly, radiology did not call a pneumothorax. It was only a faint sliver if it was there.

How did the air get there if there were no pneumothorax?

It was thought that this elderly woman's lung had scarring, so when the rib pierced the lung, the fibrosed pulmonary tissue stayed adherent to the thoracic wall. The air had to go somewhere, so it went freely into the chest wall instead of accumulating in the pleural space.

As with most cases, the air resorbed over the next week or so without further incident.

Tip to Remember: Look at the whole radiograph, not just the area of initial clinical concern. Tunnel vision can miss significant abnormalities. After looking at the area of clinical concern, view the entire image, or a significant finding can be overlooked.

Thursday, January 2, 2020

A Classic Fist Fight Injury

​A right-handed man presented with swelling and tenderness at the base of his thumb after an altercation. His range of motion at the metacarpal-carpal joint was limited because of pain. Not unexpectedly, his first metacarpal was broken. What can you tell this patient about his injury?

LTB-x-ray-Bennetts fracture-metacarpal-carpal joint.jpg

You can say:

  • This fracture has a name: Bennett's fracture.
  • It is the most common fracture of the base of the thumb.
  • His fracture is classic in mechanism; fist fights commonly produce this injury (by having an axial load against a partially flexed first metacarpal).
  • His radiographs are classic in appearance—a two-piece intraarticular fracture with an oblique fracture line. (Note that if it were in three or more pieces, it would be called a Rolando fracture.)
  • These fractures are considered potentially unstable. The small metacarpal fragment stays attached to the trapezium through the anterior oblique ligament. The metacarpal, however, may be pulled dorsally and proximally by the abductor pollicis longus, causing subluxation or dislocation.
  • Poorly aligned fractures can lead to instability, osteoarthritis, chronic pain, and disability.
  • Operative management is recommended for fractures with joint instability, articular incongruence, or open fractures.
  • Splinting in thumb extension should be avoided because this can exaggerate the displacement.
Tip to Remember: Bennett's fractures need to be seen by an orthopedist or a hand surgeon in a timely manner to minimize long-term disability and pain. Refer early, and do not splint in extension.