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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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Thursday, October 1, 2020

​This 20-year-old right-handed patient came in with an obvious deformity of his hand after hitting a wall. Can you see two clues to the injury with just this AP film?

LTB-x-ray-hand injury-boxers fracture.jpg

I'd surmise that your eyes are drawn to the fifth metacarpal, which is good because this looked like a boxer's fracture. Boxer's fractures, however, are most frequently at the fifth metacarpal neck. There was no fracture, but the fifth metacarpal head seemed way too close to the fourth. The angle of the bone was all wrong. It should be pointing out, not in.

I'll give another hint: The deformity seemed to be at the base of the fifth metacarpal. Now what do you see?


Notice anything strange about the hamate to fifth metacarpal joint? The bones were overlapping! The joint should normally have about a 2 mm gap. OK, the index finger didn't seem to have that gap. This is true. Sometimes anatomic variation can make the first and second metacarpal carpal joint look funny, most probably because of the need to have wide range of motion of the thumb. From 3 to 5, the joint line should be a parallel M.


The internal oblique clearly showed the fifth metacarpal dislocation with a small avulsion off the hamate. These injuries are uncommon, but when they do happen, the mechanism is often hitting a wall. An ulnar nerve block or conscious sedation should make this go in relatively easily.

LTB-x-ray-internal oblique-fifth metacarpal dislocation-hemate avulsion 2.jpg

And it did!

Tip to Remember: Check the metacarpal-carpal joint line. From at least 3 to 5, there should be a 2 mm gap the entire way across.

Tuesday, September 1, 2020

That was the chief compliant. Right away, I was skeptical because it seemed rare that something was actually stuck in a patient's throat.

Long ago, I had moved away from plain x-rays to CTs for this complaint. Direct visualization was fraught with problems. I just didn't do it enough to feel confident that I would be able to see an embedded fishbone among the glistening saliva. It was possible that it could be so buried in soft tissue that I could not see the top.

I thought I had already seen the future path before I drew back the curtain.

Lying comfortably on his side was a 22-year-old man with rock solid vital signs, an entirely normal physical exam, and no previous medical history. "So you have something stuck in your throat," I said flatly, more as a statement than a question. He replied just as flatly, "No." Now he had my attention. "Where?" He pointed to his sternum right between the nipple line.

"What happened?"

He told me that he had been eating sesame chicken when it had gotten stuck. He knew the uncomfortable feeling because he had had it before. Like those times, he would "fill up" and "vomit spit" every few minutes. Every time before, it eventually passed, he said. It could not have been a more classic description of a food impaction.

With nothing but that description, I called GI at 8 p.m. on a weekend. An hour or so later, the endoscopy suite was opened, and he left the ED. Another hour went by, and I was called to come to the desk. There stood the gastroenterologist with pictures.

"I think he has eosinophilic esophagitis," he said. "I did biopsies, but I have pictures. After I got the food out with a snare, there were these longitudinal furrows and white plaques. There is a grading score for this. His was rings 1, exudates 2, furrows 1, and strictures 0. I'll let you know."

As he left, I smiled. Sometimes patients don't have a history until they do. We in emergency medicine help them get to that history so that they are put on the right path to get the help they need.

Tip to Remember: Sometimes the story is good enough.

LTB-food impaction-eosinophilic esophagitis.jpg

LTB-eosinophilic esophagitis.jpg

Monday, August 3, 2020

"Wow! That is massive," I said. "What happened?"

The patient had a long-term trach. I had sent her to the ICU earlier after she arrested and ROSC was obtained. Her post-code radiograph revealed a right-sided pneumothorax. A chest tube was placed. A little while later, there was air everywhere.

LTB-x-ray-pneumothorax-massive subcutaneous emphysema-angiocatheters.jpg

 Could there have been a tracheal injury or lung injury during CPR or a problem with the chest tube placement? I didn't know, but I did know it was getting much harder to ventilate her and her skin soft tissues were becoming tense. Respiratory embarrassment and circulatory collapse were real possibilities. Compression of the vascular neck could also cause death.

This was truly a massive subcutaneous emphysema, and intervention was warranted. "Blowholes," I said, like it was some kind of boards word association answer. I couldn't remember all the details. A quick consult with Dr. Google produced a reassuring video that a couple of infraclavicular cuts would do the trick. (https://bit.ly/3d9oAbs.)

Later investigation revealed that regular angiocatheters stuck in various places around the chest wall had the advantages of being low-cost, simple, quick, high efficacy, and well tolerated. I wish I would have known that angiocatheter placement was effective. I wouldn't have hesitated to take that step.

Tip to Remember: Massive subcutaneous emphysema can kill. One can relieve some pressure by sticking an IV needle into the subcutaneous tissue or making incisions in the skin (most commonly infraclavicular blowholes).

LTB-x-ray-pneumothorax-massive subcutaneous emphysema-infraclavicular blowholes.jpg

Wednesday, July 1, 2020

​As I looked over my patient's elbow images, he asked, "Is it terrible?"

LTB-terrible triad-elbow injury-intra-articular fracture.jpg

I sighed. "It just might be terrible."

My eyes had immediately centered on the little avulsed piece of bone, then to the posterior fat pad. The pathologic posterior fat pad confirmed this as an intra-articular fracture. My focus shifted to the radial head, but I was unable to identify a radial head fracture. Still, I pondered the possibility that the assault had caused the terrible triad of elbow injuries.

Isolated coronoid process fractures are rare and come in three types:

  • Type 1: Fracture of the tip.
  • Type 2: Fracture of about 50 percent of the coronoid process.
  • Type 3: Fracture of more than 50 percent of the coronoid.

I called this a type 1, but that did not give me any comfort because it can be associated with elbow dislocations and radial head fractures—the terrible triad. Sometimes the elbow reduces spontaneously, and you need a high index of suspicion for significant injury whenever a coronoid process fracture is seen. Other soft tissue injuries can also occur, such as lateral collateral ligament tears.

LTB-terrible triad-elbow injury-coronoid tip fracture-x-ray.jpg

A diligent search of other views showed only the coronoid tip fracture. An elbow CT confirmed an isolated injury, and it was stable on physical exam. Unexpectedly, it was not as terrible as first feared.

Tip to Remember: Isolated coronoid process fractures of the ulna are uncommon. Always consider any coronoid fracture a red flag for the terrible triad of elbow injuries and a potentially unstable elbow.

Monday, June 1, 2020

​"He's not sure how he did this," my colleague said. "He said he accidentally stepped on a toy in the living room, twisted his ankle, and fell to the ground. What would you call this?"

LTB-x-ray-exorotation fracture-posterior malleolus.jpg

I love emergency orthopedic radiography, and there was more than one answer. I would give three, but one was better than the rest:

  • Weber C distal fibular fracture
  • Trimalleolar fracture equivalent
  • An exorotation fracture, likely supination

The Weber classification describes distal fibular fractures based only on whether the fracture is above, below, or at the syndesmosis. Weber Type A fractures are below the level of the tibial plafond and stable. Type C fractures are above the level of the tibial plafond and unstable. The rule of the ring mandates looking for a second fracture. Type B fractures at the level of the syndesmosis could be stable or unstable.

Bimalleolar and trimalleolar fractures are common terms related to ankle fractures. In this case, the oblique fibular fracture above the syndesmosis and the tertius fracture (posterior malleolus) are clearly seen. One might think that this would be a funky bimalleolar fracture involving the lateral and posterior malleoli, but that would be wrong. The medial aspect of the ankle has an obvious injury. The AP ankle view displays a tilted talus. The mortis view is much more gapped on the tibial side than the fibula side. One must suspect deltoid ligament damage. Because there is no bony injury on the medial side, this is considered a trimalleolar equivalent.

The Lauge-Hansen classification of ankle fractures is more complex. It explains the fracture mechanics to a greater extent, however. There are two movements to consider: supination or pronation and side-to-side or rotary movement of the talus. The combinations yield four potential outcomes. The side-to-side movement of the talus directly knocks the fibula. These fractures tend to be transverse and less likely to involve the posterior malleolus. On the other hand, rotary movement of the talus tends to cause increasing grades of injury, resulting in the tertius fractures at the posterior malleolus.

The four stages of a supination-external rotation injury are:

Stage 1: Anterior tibiofibular ligament rupture

Stage 2: Spiral or oblique fracture of the fibula

Stage 3: Posterior tibiofibular ligament with or without a tertius fracture

Stage 4: Deltoid ligament rupture with or without a medial malleolus fracture

Describing a fracture in an orthopedist's language can create confidence in your knowledge. The best answer would be the last one—an exorotation injury.

Tip to Remember: Rotational injuries of the ankle have oblique rather than transverse fibular fractures, and often involve the posterior malleolus.

Video Reference

"Ankle Fractures-Everything You Want to Know-Dr. Nabil Ebraheim," YouTube. August 26, 2016; https://bit.ly/3bcsVJJ.