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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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Tuesday, June 1, 2021

June 2021: Will This Patient Need a New House?

​I love to test myself to see if I can guess what I am going to see with the minimum number of films. I played this game recently when looking at this man's knee film. He had been drinking and slipped walking down a set of stairs.

With one glance and one film, I knew I had to order another film.

Lions Tigers and Bears 1.png 

The patient was distraught about his recent knee replacement. He was sure he had messed it up. He could barely contain his frustration that I went straight to his ankle. I explained about potential other injuries as I palpated the medial malleolus.

He did not have much swelling, but I rationalized it away by thinking it might be too early. He had come in right after his fall, and the lack of pain could be discounted by the alcohol. I waited for the ankle films, and I was sure I would see a widened mortise and likely a medial malleolar fracture. My mind whispered, "You won't need to give this guy a new house."

Lions Tigers and Bears 2.png

It wasn't what I expected! The fracture was on the wrong bone, but it did not violate the rule of the ring. I saw two fractures, just like when a ring is twisted to its breaking point. This is not unheard of in the literature. The Maisonneuve variant of a proximal and distal fibular fracture had been seen before. I wondered if I would have known before the film if I had examined the lateral malleolus more.

 Tip to Remember: When you see a proximal fibular fracture, think of the new house the patient may get if you don't image the ankle. This is the way you can pick up the Maisonneuve (which means new house in French) fracture. (Clin Orthop Relat Res. 1995 Aug;[317]:193.)​


Friday, April 30, 2021

May 2021: The Elusive Tibial Plateau Fracture

​"Can you check this guy's knee? He was hit by a car," the APP said, adding that she hadn't seen anything on the x-ray.

The patient winced when I touched the area around the fibular head. Images flashed in my mind from 30 years ago when I missed a lateral tibial plateau fracture. The patient walked on it, displacing an undisplaced fracture, and he required surgery. I hadn't forgotten about him decades later.

LTB 1.jpg

This patient's AP film looked fine: no break in the cortex. The trabecular pattern looked normal, but it was just one view.

LTB 2.jpg

The oblique raised a tiny question—or was I just imagining things? Was there really a faint break of the cortex at the lateral tibial plateau? Would a CT tell us for sure?

I knew this would increase the length of stay. It would probably be a mark against me, but it felt like the right thing to do, especially in COVID-19 times. It would be much easier to make the definitive diagnosis from the emergency department.

LTB 3.jpg​

There it was, just as expected. He had an undisplaced lateral tibial plateau fracture. We wanted to keep it that way. I emphasized to the patient that he should not bear weight until the orthopedist said he could. He went home with a knee immobilizer, crutches, and a follow-up appointment.

Tip to Remember: Undisplaced tibial plateau fractures can be subtle and difficult to see. Get a CT if you're unsure.




Thursday, April 1, 2021

April 2021: ​Name that Fracture

Growing up in the ’70s, I loved the game show, “Name That Tune.” I was enthralled by the challenge of guessing the correct answer with the barest of clues. I marveled at the knowledge of those contestants who said they could name a tune in one note and who were proved right when the entire song was played. I wanted to have the expertise to say the answer with conviction before all was revealed.

I never got that good with music, but I found a corollary in the emergency department in which I wished to excel. How many radiographs did I need to know where the fracture was? Could I know from subtle signs on just one view that was then confirmed by the series?

I again had the chance to play the game when this lateral elbow popped up on the screen. The historical clue given: slipped on the ice, elbow hurts.
LTB 1.png
 
The anterior and posterior fat pad jumped out at me. Posterior is always pathologic. Not pediatric because no growth plates were present. If the patient were a child, I would look toward the humerus for a supracondylar fracture, but the culprit almost always hid in the proximal radius in adults. I didn't see the defect on the lateral, but I was sure it must be there.

LTB 2.png

And there it was: a nondisplaced radial neck fracture!

April LTB 3.png
 
Tip to Remember:  Adults tend to break their radial head and neck with falls. When you see a posterior fat pad, pay extra attention to the radial head and neck on all views. Suspect a supracondylar fracture in children. 

Monday, March 1, 2021

March 2021: Injury Without Trauma

She was actively holding her arm against her side, her hand wrapping around her wrist. Any attempt to move her shoulder, actively or passively, brought an involuntary wince of pain. Tears quickly followed.

My patient, a woman in her 40s, described increasing diffuse shoulder pain over two days. There was no trauma, but she described excruciating pain. She couldn't raise her arm at all, so I thought about a rotator cuff injury.

She had had no injury, but rotator cuff tendons can give way to repetitive injury that thins the tissue until one day it just it breaks. It seemed more agony than this etiology would give. Maybe there was more to the story. Could an x-ray help?

LTB 1.png 

There was the answer: calcific tendonitis of the supraspinatus muscle. This is the most common location of calcific tendonitis and completely explains this patient's tortured shoulder. Pain can be caused by chemical irritation from the calcium deposits in the tissue, tissue swelling causing pain, or a subacromial impingement syndrome.

This is actually a classic story. Patients with symptomatic calcific tendonitis are most commonly women between 30 and 50 with exquisite, atraumatic shoulder pain. The treatment is NSAIDs. If steroids are used, this is most commonly by injection. For those rare cases that are more resistant, removal of the calcium deposit may be required by excision or ultrasound-guided barbotage.

Tip to Remember: Sometimes orthopedic radiographs are helpful even when there is no trauma.

Friday, January 29, 2021

February 2021: The Rule of the Ring

​"I think they broke my wrist. It hurts all the way up my arm."

Responding reflexively, I said I would get a wrist x-ray. Given the odds, I immediately guessed this might be a Colles fracture. The patient said his wrist hurt all over, but pointed specifically to the distal ulna. That's atypical. Not the distal radius?

We would see when the x-ray was done. Then we would know.

LTB 1.png

 

The distal ulnar neck fracture was obvious. The break was close to the distal radioulnar joint (DRUJ). Should I be concerned? I ran through my DRUJ checklist:

Is the ulna snuggled in the sigmoid notch? Check.

Is the radioulnar joint line aligned? Check.

Is the ulnar styloid intact? Check.
 
One view, however, is not enough to be confident that the ulna is in place. I switched screens to the true lateral.

LTB 2.png

There was no subluxation or dislocation. The radius and the ulna lined up perfectly. Still, should I be concerned?

In emergency medicine, we talk about the rule of the ring: It is difficult to break a ring in just one place, so consider a second fracture whenever there is a bony ring. This is the truth of Maisonneuve fractures of the leg. In this case, I was already sure that it was not a Galeazzi because the distal radius was intact.

Could I be seeing an Essex-Lopresti injury? The patient did say he hurt all the way up the arm. Maybe that interosseous membrane had been torn to shreds. I ordered imaging for the entire forearm, particularly obsessed with the radial head.

LTB 3.png

LTB 4.png
The radiocapitellar line was intact. No dislocation. No Essex-Lopresti. It seemed the patient only had a very distal nightstick fracture. Still, it was worth going through the checklist because DRUJ injuries and Essex-Lopresti injuries could have been missed!

Tip to Remember: Injuries to the distal radioulnar joint can be easily missed. Have a RDUJ checklist, and remember the rule of the ring!