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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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Thursday, November 1, 2018

A Rare Fracture

​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

A Textbook Case

​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

A False Appearance of Fine

​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.​

Wednesday, August 1, 2018

See Me Now

​A young woman with known psychiatric illness and a tendency toward self-injury was sent to the emergency department for medical clearance. She had presented in the past after ingesting objects, so an upright chest and KUB radiograph were obtained.​

LTB razor 1.jpg

LTB razor 2.jpg

Nothing unusual popped out at first glance, but it was an entirely different story when magnified in a dark room. The sharp square edge extending beyond the vertebral body was impossible to miss. The four holes confirmed she had almost certainly swallowed a razor blade. Inversion made it even easier to see.​

LTB razor 3.jpg

LTB razor 4.jpg

LTB razor 5.jpg

Identifying the object is only half the battle. What is the next step?

We performed a CT scan to determine if the razor was still in her stomach or if it had passed beyond the pylorus into the small bowel. It was clearly shown to be in the stomach. Endoscopy was emergently arranged because sharp objects such as razor blades have as much as a 35 percent perforation risk at the ileocecal valve. (Gastroenterol Rep 2014;2[2]:158; http://bit.ly/2lSHScY.) The razor was removed uneventfully.

Interestingly, multiple references pop up if one searches online for razor blade ingestion. It seems prisoners are a particularly at-risk population. (Ulster Med J 2008;77[2]:110; http://bit.ly/2z86XtM.) Even more interestingly, almost all reports in cases and case series have shown that conservative management of razor blades that pass beyond the pylorus traverse the entire route of the bowel without difficulty. Still, I was glad we got it while it was still in the stomach.​

Tip to Remember: Maximize your ability to identify abdominal foreign bodies with magnification and image inversion in a dark room.

​

Monday, July 2, 2018

Look for the Signs

​An AP image of a shoulder flashed up on the screen. My colleagues often bring me interesting, rare, difficult, and classic cases because I write this blog. All are intellectually stimulating cases that remind me of the exciting parts of being an EP. It's a challenge to see how many clues I can find to make the diagnosis. These short interactions also help me form stronger bonds with my colleagues, a bonus for my interest in wellness.​

LTB posterior shoulder 1.jpg

First, my eyes were drawn to the wide glenohumeral interval. The space is huge (yellow lines in photo below). The glenoid appeared vacant. It also showed the rim sign where the glenoid rim can be seen without overlap. The normal half-moon appearance of the superimposed glenoid and humeral head was gone.

Next, the shape of the humeral head was wrong. It looked like a lightbulb when it should look like a club (blue circle).

And the normally smooth Moloney's arch formed by the medial scapular border and down the humeral shaft had a point (purple inverted V). It should be a Romanesque arch, not a peaked Gothic one. Moloney's arch is just like the gently curved, continuous, contoured Shelton line in the hip. It wasn't right either.​

Finally, there was a subtle "M" (red lines) made by the contours of the greater and lesser tuberosity in the internal rotation. This is a Mouzopoulus sign.

​LTB posterior shoulder 2.jpg

This must be a posterior dislocation.​

The screen on the Y view confirmed that to be correct. The humeral head sat under the acromion (yellow circle) instead of in the glenoid fossa (red circle). In anterior dislocations, the humeral head sits near the anteriorly located coracoid process (blue circle).

LTB posterior shoulder 3.jpg

LTB posterior shoulder 4.jpg

Tips to Remember:

-Posterior dislocations are often missed. Remember to look for all the signs, including the vacant glenoid sign, the rim sign, the half-moon sign, the light bulb sign, the normal contour of Moloney's arch, and the Mouzopoulus sign to get the diagnosis.

-Share interesting cases with your colleagues. It makes our jobs more intriguing, and reminds us why we do what we do.

Reference:

  1. Weerakody Y, Radswiki et al. Posterior Shoulder Dislocations. https://radiopaedia.org/articles/posterior-shoulder-dislocation​