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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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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.

Saturday, September 29, 2018

We went together, the med student and I, to check the eye complaint of a man who had been assaulted a few hours before. The student quickly decided we needed a facial CT to rule out a fracture. I asked him what kind of fracture he suspected; an orbital blowout fracture, he said.

I asked the patient to look toward his nose, and a prominent lateral subconjunctival hemorrhage popped prominently into view. This is truly a red flag for a more complex midface fracture. Finding zygomatic arch tenderness, I wondered aloud if our patient had a zygomaticomaxillary complex fracture.

LTB midface fracture 1.jpg

There seems to be little need to have a framework to consider mid-face fractures these days. Most of us have ready access to a CT scanner, and a radiologist gives us our answer. I grew up medically in the era of plain facial films, however. We needed to have a mental schema to consider the bony blunt force injury to the face. I divide the face into thirds:

  • Upper third: Above the eyebrows; rarely fractured in blunt trauma.
  • Lower third: The mandible; often fractured, but clinical cues are helpful: two areas of pain, step off of teeth, inability to bite down on a tongue depressor.
  • Middle third: Upper teeth to eyebrows; often fractured in simple and complex ways.

Simple and complex can be defined as:

  • Simple: Nasal fractures, blowout fractures (medial and inferior), and isolated zygomatic arch fractures
  • Complex: LeFort fractures and zygomaticomaxillary complex fractures

Zygomaticomaxillary complex (ZMC) fractures involve multiple midface bones including the zygomatic arch, the inferior orbital rim, the maxillary sinus walls, and the lateral orbital rim. Essentially, there is a free-floating chunk of bone inferior and lateral to the orbit. These fractures have been known by many other names, including tripod, trimalar, tetrapod, and quadripod fractures. Clinically one might note trismus from impingement on the muscles of mastication, inferior orbital numbness from a traumatized inferior orbital nerve, or a lateral subconjunctival hemorrhage.

I opened up the bony reconstruction to see if the images matched my imagination … and clinical suspicion. There it was, as if I were reading a textbook: a ZMC fracture (or tripod, as I had called it in training a quarter century ago).

Tip to Remember: Think ZMC fracture when you see a lateral subconjunctival hemorrhage.

LTB midface fracture 2.jpg

LTB midface fracture 3.jpg

Friday, August 31, 2018

​Like a million times before, the tech thrust an ECG in front of you. This one, however, grabbed every neuron's attention. Who was this?​

LTB-BRASH1.jpg

The tech says the patient is a 70ish-year-old diabetic, hypertensive man brought to the emergency department because he has been feeling weak from a couple days of diarrhea.

Where was he? Was he talking? What was his blood pressure?

The tech pointed at one of the back rooms, and said, "Oh, his blood pressure is good—138/71, and he is talking to his family."

He did look pretty good. His heart rate was 37 bpm as he chatted with his family. Staring back at the ECG, I think maybe I should rethink my initial thoughts of atropine and pacer. Maybe this guy needed a different drug or a different intervention. Maybe he needed calcium and perhaps a Foley.

The labs returned rather quickly confirming these thoughts. His potassium was 8.2 mEq/L, and the creatine was 7.0 mg/dL. This patient may well be on the way to a full-blown BRASH syndrome with four of the five components, which include:

B: Bradycardia

R: Renal failure

A: AV nodal blocker

S: Shock

H: Hyperkalemia

(PulmCrit. Feb. 15, 2016; http://bit.ly/2LVi6QD.)

BRASH occurs when poor renal perfusion leads to renal insufficiency or failure, which causes the AV nodal medication and potassium to build up in the bloodstream. They combine to produce the bradycardic picture, which ultimately will result in shock with potentially severe hypotension. This cascade is often set off by hypovolemia, such as the diarrhea this patient experienced. Often these patients may appear better than expected, and they may not exhibit the typical ECG findings of hyperkalemia beyond the bradycardia.​

This patient was given calcium, D50, insulin, and fluids for his hypovolemia. It was noted that he had urinary retention with a Foley draining a liter for urine. By the next morning, his ECG had returned to normal. Looking back, he probably had more ECG stigmata of hyperkalemia. The QRS complex narrowed significantly, and now the T's in V2 seemed more peaked than initially appreciated.

LTB-BRASH2.jpg

Tip to Remember: Take a minute to think hyperkalemia with bradycardia.​