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Monday, November 30, 2020

Procedural equipment will help you make accurate diagnoses and formulate treatment plans. You want the equipment to work, be readily accessible, and be easy to clean and store. It's also nice when it fits in your pocket.

You also want to be sure your staff is trained to use it. Not everyone in your department may want to break out the nasal endoscope for a quick ENT exam, as we discussed last month. (See post below.) But specialized ENT equipment may make your life a bit easier and improve patient outcomes.

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Using a digital otoscope to view the tympanic membrane is fast, easy, and safe. This particular model costs $24. Photos by M. Roberts.


The traditional bedside otoscope provides a basic but limited view and magnification of the tympanic membrane. The bulbs on these lights are usually dim and a poor choice for accurately visualizing smaller areas, such as nasal or oral lesions, active bleeding, small foreign bodies (such as fish bones), or even tiny tympanic membrane perforations.

Most otoscopes consist of a handle, a head with a light source, and a low-powered magnifying lens, typically capable of only 6-8 diopters. More complex otoscopes offer heads with fiberoptic enhancement and magnification (up to about 30-40% more magnification and twice the field of view), and can be used on most standard otoscope handles interchangeably. Replaceable heads can cost anywhere from $500-$2500, and many brands and choices are available.

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The parts of a handheld digital otoscope. Photo by M. Roberts.


Digital otoscopes are the wave of the future. The provider can use these tools to examine a patient's ear, nose, and throat more effectively than with standard otoscopes. (Association of American Medical Colleges. Sept. 18, 2015; https://bit.ly/31U8srA.) They can also be used for cerumen impaction. A digital otoscope incorporates a camera, LED lighting, and enhanced magnification.

These devices are easy to clean (Korean J Otorhinolaryngol Head Neck Surg. 2016;59[8]:578; https://bit.ly/2TCDtvA) and portable, and they allow immediate capture and storage of images and video. An otoscope fits into the ear, nose, or mouth easily and safely. They can also be used with a disposable speculum or spatula of varying sizes for cerumen or foreign body removal. The device is easy to hold, and consists of a small, tubular camera the size and width of a pencil with a cord that can be attached to a phone or computer. Many are compatible with iPhones, Android phones, Macs, and PCs. Some electronic medical records allow you to store images. This allows you to add your initial and repeat evaluations to the patient's chart to track progress and enhance the treatment plan. Many EMRs have the ability to store images in compliance with HIPAA, but some do not. Make sure you are compliant with your hospital's policies. Taking pictures on your personal device may also need a consent form.

There are several versions of basic digital otoscopes, many for $20-$100 online. Digital otoscopes may be of greater value during the COVID-19 pandemic. They are useful to have in your pocket, and may even be used via telehealth. (Laryngoscope. 2020;130[6]:1572.) If the patient has a chronic ENT or skin condition that needs ongoing management, these devices may be a cost- and time-reducing alternative to an ED or urgent care visit. Anyone can be trained to use them.

The digital otoscope can also be used to examine the skin and identify lesions. This may not be a part of an urgent or emergent evaluation, but discovering a concerning lesion and referring your patient to dermatology can be life-changing or even life-saving.

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Zooming in on this age spot, top, shows it is not suggestive of a basal or squamous cell carcinoma. The otoscope also allows a closer look at a nevis, bottom.

TypeProsCons
Traditional otoscope
  • Can complete insufflation
  • Relatively inexpensive
  • Easily accessible
  • No significant upkeep
  • Rechargeable
  • Limited magnification and dim lighting
  • Not useful for complex skin, nasal, or throat exams
  • Requires being very close to patient for exam
  • Does not allow capturing of images
Enhanced otoscope head
  • Can complete insufflation
  • Twice the field of view of traditional otoscopes
  • 30 percent more magnification
  • Improved views of the nose, throat, and skin
  • Same as traditional otoscopes
  • Can be expensive
Digital otoscope
  • Improved visualization during ENT or skin exam
  • Uses a disposable speculum
  • Enhanced magnification and lighting
  • Less expensive than traditional and enhanced otoscope heads
  • Connects to a computer or phone to transmit or record images and videos
  • Examiner can be distanced from the patient
  • Cannot complete insufflation
  • Speculums may not be universal
  • Bulbs and LEDs are expensive to replace

 

Watch a video demonstrating the use of a digital otoscope.


The Literature
Digital otoscopes are currently making their way into the hands of ED and urgent care providers as well as clinics, offices, and telehealth, which can decrease health care costs, avoid exposures during pandemics, and allow follow-up with patients.

Digital otoscopes may be unsafe and cause injury in unskilled hands. (Telemed J E Health. 2003;9[4]:325.) Keep this in mind when talking about these gadgets with your patients, and continue to suggest follow-up in the office whenever possible.

Cleaning Otoscopes
Your equipment is a party zone for pathogens and bacteria. If you use a piece of equipment on one patient, it must be cleaned (cord and all) before being used on another patient. Your personal equipment (such as iPhone or laptops) may also need specialized cleaning equipment.

Apple and Android Central says you may clean iPhones and Android phones with isopropyl alcohol as long as it doesn't touch the screen. Both companies discourage using bleach-based cleaners.

One study found that 90 percent of all otoscopes are covered in bacteria, including staphylococcus (85.4%; 54.5% S. aureus and 45.2% methicilllin-resistant S. aureus). It also showed that cleaning with isopropyl alcohol reduced the colony count by an average of 96.3 percent. (Fam Pract. 1997;14[6]:446.)

A 2016 study showed that isopropyl alcohol alone was effective for sterilizing otoscopes and supportive equipment (such as cones, speculums, etc.). Staph species were also found in this study to be the most common microorganism. (Korean J Otorhinolaryngol Head Neck Surg. 2016;59[8]:578; https://bit.ly/2TCDtvA.)

Finally, a prospective, randomized, double-blind study showed that even 66 percent isopropyl alcohol is effective for cleaning surfaces of personal equipment such as a stethoscope. (Indian J Med Sci. 2004;58[10]:423.)

Some studies suggest that the coronavirus can live on surfaces for up to several hours and even days. (National Institutes of Health. March 24, 2020; https://bit.ly/2TApAhl.) The CDC has a complete guide on cleaning surfaces for COVID-19: https://bit.ly/2ybHwaQ.

Martha Weighs In:

  • I like trying out all kinds of tools that improve patient care. You can stick with what you know, but don't be afraid to try something new.
  • Be sure to check on your hospital's policy about using equipment; it may need to be checked by central processing.

 

Jim Weighs In:

  • Get your own stuff if it's allowed.


(We have no financial disclosures.)


Wednesday, October 28, 2020

Fiberoptics and endoscopy have changed the way we treat patients in the emergency department. Endoscopes are relatively easy to use, and can aid your diagnosis and treatment plan. Endoscopy may be useful in urgent cases, such as epistaxis, nasal foreign bodies, and ear debridement. It may also be helpful when dealing with more complicated presentations and critically ill patients, such as those with Ludwig's angina, epiglottis, tracheostomies, or those who need intubation.

Fiberoptic tools are not just for surgeons and consultants. The endoscope has many uses in the emergency department, and we have a few tips and tricks for nasal endoscopy, or nasopharyngoscopy. We suggest attending an airway course to properly buff up on mastering trach, video laryngoscopy, and intubation techniques, or partner with your ENT and airway team next time they visit your department.

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The flexible endoscope. Photos by M. Roberts.

The endoscope magnifies what your eye normally sees with better lighting. The body of the endoscope is a light source that extends into a flexible tube that can be used for direct visualization of the anatomy and even for suction and secretion removal. Usually, the procedure can be done on an awake and alert patient. It's great for kids, and a little IM or IV ketamine can help with sedation.

When done correctly, the patient can assist with her exam by swallowing, stimulating her vocal cords, and coughing. The scope itself causes only a small tickling sensation to the nose and throat and sometimes an increased gag reflex. Discuss the procedure with the patient so she knows what to expect before you start. Lidocaine lubricant can also be used to help numb the nasal passages, although normal saline or plain lubricant is often just as effective and inexpensive.

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Our patient was examined in a sitting position. Use both hands to guide the scope when entering the nasal cavity. Use your nondominant hand to insert the flexible tip while your dominant hand advances the scope. Photo by M. Roberts.

Equipment

  • Flexible nasopharyngoscope, fiberoptic or digital chip-on-the-tip technology.
  • A viewing camera can be attached to the viewing port of the scope (if it's not a digital scope).
  • Additional light sources and suction as needed.
  • Disposable endoscopic sheath.
  • Cleaning equipment for the endoscope: chlorine dioxide multi-wipe system, endoscope washer-disinfector units, etc.
  • Topical decongestant or anesthetic spray as needed, normal saline, or lubricant.
  • Alcohol wipes to clean the camera lens.
  • Culture swabs if needed.

Source: StatPearls. Aug. 8; 2020; https://bit.ly/30zKUaF.

The Approach

Nasopharyngoscopy using the three-pass technique.

The Pause

Do not do this in patients with suspected epiglottis or croup unless with a specialty or experienced provider. The risk of laryngospasms is reported in less than one percent of procedures. (StatPearls. Aug. 8; 2020; https://bit.ly/30zKUaF.)

The Three-Pass Technique

  • First pass: The scope is passed along the floor of the nasal cavity into nasopharynx.
  • Second pass: The scope goes between middle and inferior turbinates.
  • Third pass: The scope is advanced farther down the back of the retropharyngeal space to visualize the epiglottis, glottis, and vocal cords. Stop to examine all areas along the way.

The Procedure

  • Put the patient in a sitting position.
  • Encourage the patient to breathe normally throughout the exam. Swallowing is OK.
  • Make sure your light source works before you put the scope in the nose.
  • Lidocaine and epinephrine or xylometazoline can help to numb and decongest the nose if there is mucus or edema, and should be used at least five minutes before your examination.
  • Visualize the nasal passages externally, and enter the larger nostril. Pro tip: If you have the patient smile, the nostrils will expand, and you can choose the bigger of the two.
  • Insert the scope slowly, observing the anatomy.
  • Identify foreign bodies, inflammation, masses, or polyps along the way. You can identify sites of anterior bleeding.
  • Once you pass through the pharynx, through the retropharyngeal space to the oropharynx, you will see the epiglottis and vocal cords. At this time, it's important to know what is normal and abnormal, identify any irregularities, and then formulate your diagnosis.
  • Remove the scope in a swift but gentle motion, and clean and sanitize appropriately before storing it in a soft, padded case to protect the integrity of the scope and camera.

Additional Key Steps for Patient Participation

  • Have the patient say "Eeee" and "Aaaahhh" to see the vocal cords move. The vocal cords should move equally. If there is a laryngeal mass, these sounds will make them more visible.
  • Have the patient stick out his tongue to better visualize the vallecula (the depression at the root of the tongue).
  • Have the patient puff out his cheeks and move his head from side to side. This may also help you better visualize the anatomy.
  • Have the patient sniff and swallow.
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If your endoscope comes with a larger broadcasting video screen, you can turn it on and connect the device easily. Some endoscopes can connect to a smart device. If you do not have other viewing devices, you can use the magnifying piece directly on the endoscope for visualization. Photo by M. Roberts.

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Anatomy review. Source: markgium and Indolences, Creative Commons.

See our video demonstrating a nasal endoscopy in the ED on a patient with sinus cancer.

Aerosolizing Procedures and COVID-19

Any aerosolizing procedure done during the coronavirus pandemic can be dangerous for the provider. It is expected that you follow your hospital's guidelines for this practice and wear appropriate personal protective equipment (PPE).

Diseases and pathogens that are airborne or droplets are considered hazardous when performing these procedures. This includes COVID-19 patients and SARS-CoV-2. Promptly identify these patients or potential patients. If uncertain, consider appropriate PPE for your procedure.

Perform hygiene before and after entering rooms. Limit the number of necessary staff during your procedure. Don and doff PPE appropriately. PPE may continue to change and evolve during the COVID-19 outbreak, so be sure to know the appropriate PPE offered by your facility. This may include a powered air-purifying respirator, N95 mask, restrictive airtight goggles, other face and nose coverings, gowns, gloves, shoe covers, hair covers, and more.

The CDC updates PPE recommendations frequently: https://bit.ly/2Gt6erl. Many diseases and pathogens besides the coronavirus require airborne precautions such as anthrax, avian influenza, measles or rubeola, monkeypox, SARS or MERS, tuberculosis, varicella zoster (chickenpox), and herpes zoster (Varicella) or shingles. (CDC. https://bit.ly/3ldhTcE.)

Diseases and pathogens that require droplet precautions include diphtheria, Haemophilus influenza type b (Hib) disease in infants and children, epiglottitis due to H. influenzae type B, seasonal influenza, meningitis, meningococcal disease (Neisseria meningitidis) sepsis or pneumonia, mumps/parotitis, Mycoplasma pneumoniae, parvovirus B19, pertussis, pharyngitis in infants and young children with adenovirus, Orthomyxoviridae, EBV, or herpes simplex, pneumonia with adenovirus, Hib in infants and children, Neisseria meningitidis, mycoplasma or strep group A, strep disease (group A strep) for major skin, wound, burn infections, scarlet fever in infants and young children, and SARS-CoV-2. (CDC. https://bit.ly/3ldhTcE.)

Thursday, October 1, 2020

Cerumen impaction removal may not be considered an emergent procedure in the emergency department, but this omnipresent natural phenomenon will bring patients, from infants to the elderly, to your department at all hours of the day and night because loss of hearing is a foreign and uncomfortable sensation.

Cerumen impaction can cause complete hearing loss, pain, dizziness, chronic cough, and even infection. Patients who attempt to remove cerumen at home can end up with otitis externa or otitis media and even tympanic membrane trauma. The cerumen can block visualization of the tympanic membrane so TM rupture or ear infections could be missed. We are going to help you sort through the approaches and tools you need to treat this ailment quickly.

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Cerumen impaction in a 55-year-old man with chronic cerumen impactions and otitis media and externa cause by sinus cancer. Photos by M. Roberts.

Cerumen impaction is present in approximately 10 percent of children, five percent of healthy adults, and about 57 percent of older patients in nursing homes, as well as up to 36 percent of patients with intellectual disabilities. (J Am Acad Audiol. 1997;8[6]:391; https://bit.ly/336Ov0p.) Higher-risk populations will have chronic issues and visit your department frequently. Anyone, however, is at risk of complications of cerumen impaction, and those with hearing aids, who swim, or who use ear plugs are at higher risk.

At times, a foreign body may even be the cause of impaction because cerumen will form around the object to help push it out of the canal. It is not uncommon that patients will be unaware of a long-term foreign body in the ear, especially children. Finding something may be a surprise to them, and this must always be on the differential. Otitis externa or media can be treated once identified. See our prior blog on this at https://bit.ly/2ZHgQJM.

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Foreign material removed from an impaction in the ear of a patient with acute bacterial otitis externa. Photo by M. Roberts.

The best way to initially treat cerumen impaction is to examine both ears and take a thorough history. If the canal appears blocked with cerumen, there are medications (cerumenolytics such as acetic acid, Cerumenex, Debrox, Colace, hydrogen peroxide, and saline solution) that can be instilled to soften the wax. These are still only 40 percent effective. (Br J Gen Pract. 2004;54[508]:862; https://bit.ly/3idtHdP.) Using cerumenolytics in combination with gentle saline or warm tap water irrigation may be more effective. Several studies suggest that using cerumenolytics at least 15-30 minutes before irrigation may be of greater value if kept in the ear for 24 hours or more. (Aust Fam Physician. 2005;34[4]:303.) Manual impaction removal with metal or plastic loop spoons alone can be effective, but is painful and can be dangerous.

If you choose the cerumenolytic and irrigation approach, you can use a plastic catheter (such as that from an IV needle) at the end of a 10 mL syringe with tap water that is warmed to room temperature. Cold water can cause a caloric-reflex response and should be avoided.

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A cone-like device is used to precisely remove impaction. Photo by M Roberts.

What you may not know is that manual impaction removal is best completed by using a cone-like device inserted gently into the ear. A small metal cone can be gently placed in the ear to protect the canal during ear wax removal. It also helps the provider to visualize the cerumen and gently scrape out the material safely. It can also help prevent the spoon or extractor device from going too far into the canal because it can be used a marker of depth when inserted. When the cone is used, the wax will gently slide off into the cone and out of the ear, especially if the ear has been pretreated with a cerumenolytic 15-30 minutes before the procedure.

Watch a video of cerumen removal.

Irrigation v. Manual Removal v. Cerumenolytics

The 2017 guidelines from the American Academy of Otolaryngology-Head and Neck Surgery for managing cerumen impaction include removing cerumen in symptomatic patients (pain, redness, discharge, pruritis, hearing loss, fullness) as well as older patients and those with mental illness or intellectual disability. (Otolaryngol Head Neck Surg. 2017;156[1_suppl]:S1; https://bit.ly/3lWciJ3.) Patients who are asymptotic should not have routine cleaning in the ED. They may clear the impaction on their own.

Some families may swear that olive oil, grapeseed oil, or Vaseline is the best cerumenolytic to remove ear wax. Some providers may only have certain cerumenolytics in stock. In any event, a softening agent of any kind is better than none at all. Keep in mind that some cerumenolytics may cause localized reactions such as redness, rash, pruritis, or generalized irritation. (Otolaryngol Head Neck Surg. 2017;156[1_suppl]:S1; https://bit.ly/3lWciJ3.) If patients have had cerumen impaction in the past, it may be helpful to ask them what they have used for treatment.

The literature comparing the effectiveness of cerumenolytic agents, irrigation, and manual removal is limited. Systematic reviews have not found superiority of one method over the other. (Otolaryngol Head Neck Surg. 2017;156[1_suppl]:S1; https://bit.ly/3lWciJ3.) Direct visualization and experience can make this procedure more successful. Manual removal is not always easy, and can be painful and injure the canal.

A systematic review of 10 randomized trials of 11 cerumenolytics found that cerumenolytics were better than no treatment, but there was no significant difference in the efficacy of different types of drops. (Cochrane Database Syst Rev. 2018;7[7]:CD012171; https://bit.ly/3iaLNNv.) Water and saline solutions were also used and found to be similarly effective compared with cerumenolytics. Research on certain cerumenolytics shows that mineral oils may cause less irritation and drying compared with hydrogen peroxide or acetic acid. Patients with dryness or excessive exfoliation of the ear canal skin should avoid preparations containing hydrogen peroxide because it can exacerbate cerumen accumulation. Consider mineral oil and liquid docusate sodium in these patients. (UpToDate. https://bit.ly/3bBVEtk.)

Martha Weighs In:

  • Candling is dangerous. Instruct patients to avoid this practice. The U.S. Food and Drug Administration and various practice guidelines recommend that patients avoid ear candles for cerumen removal.
  • Cold water irrigation is just cruel and a good way to get slapped.
  • Do not sedate a child to remove ear wax, and consider ENT in house or referral the next day.
  • Make an attempt to remove the wax, if possible, and refer to ENT for more difficult cases.

Jim Weighs In:

  • Liquid Colace, placed in the canal for 20-30 minutes prior to irrigation, seems to work well.
  • Manual wax removal can be painful and injure the canal. Best to try irrigation first.
  • Irrigation with warm tap water using an 18-gauge IV catheter is usually effective, but it may take numerous irrigations. Don't give up too quickly.
  • It is rather common for the patient to develop otitis externa after a complicated wax removal. A few days of a topical antibiotic solution in the canal is often prescribed.
  • Do not irrigate if you are concerned about TM rupture.

Tuesday, September 1, 2020

​Outdoor recreation has exploded since we all began social distancing for COVID-19, and EDs are seeing more camping and home improvement injuries from table saws, crafting projects, and even canning (burns). Boating and motorcycle accidents also seem to be on the rise. Many fisherfolk will be on and in the water using hooks, barbs, lines, and wires. Many of these anglers will arrive with a hook in the arm, hand, or scalp, unable to remove the hook themselves. In fact, their own attempts to remove the hooks may make matters worse. Fish hook injuries may seem simple at first, but can quickly get complicated, depending on the site of injury and type of hook.

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The single-barb triple fish hook, left. Single fish hook in a patient's right earlobe. Left photo by Creative Commons, right photo by Martha Roberts.

The fish hook was named one of the top 20 tools in history by Forbes in 2005. (https://bit.ly/31d8vO3.) These prehistoric tools have helped millions of people survive for centuries. The first primitive hooks were made from shells, bones, and sticks, but today's hooks may contain several barbs embedded within fancy and flashy lures. Fish and three barbs at the end. Other materials include high-carbon or stainless steel, and they are coated with lacquer, gold, nickel, or even Teflon in a variety of colors. The type of hook will vary, depending on the type of angler. Fish hooks can also be loaded with live or artificial bait, as well as chemicals that help attract the fish.

The end of the hook that enters the fish's mouth is called the point, and it is extremely sharp. The barb extends backward from the point and allows the hook to anchor in the fish's mouth. The curved part that leads up to the other end includes the bend and shank. The eye is where the line is attached. The distance between the point and the eye is called the gap, and can vary in length. This could be useful to know if the hook is embedded deeply into the patient's skin because smaller gaps are harder to push through the skin for trimming.

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A single fish hook with a double barb.

Fish hook removal can be tricky, but there are several ways to do it. When in doubt, anesthetizing the area with lidocaine 1% is a good strategy. If the hook appears to be deeply lodged in a finger or toe, an x-ray may be indicated. Antibiotics may be required depending on the bait used (worm, chemical, etc.) and how long the hook has been in the skin.

Typically, localized and superficial reactions may be secondary to puncture wounds, are self-limiting, and do not require antibiotics. The treatment is removal of the foreign body with gentle irrigation and cleansing of the entry point. Do not try to irrigate the track of the fish hook with significant force because this will cause ballooning and destruction of the tissue. Mild surface irrigation is sufficient.

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This video highlights several techniques for removing a fish hook.

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This video shows removal of a fish hook from a patient's ear with local anesthesia.

There are four techniques for removing a fish hook: advance and cut, string yank, needle cover, and retrograde. (Roberts & Hedges, Clinical Procedures in Emergency Medicine and Acute Care, 7th edition. Philadelphia: Elsevier. 2018; Ch. 36, p. 720.)

This particular blog is very personal to us. Fishing has taught us both a lot about life in funny and strange ways. Jim removed my first hook from my head in the summer of 1990 at Lake Champlain, NY. Since then, we have fished together for 30 years from dawn to dusk. It is one of our favorite pastimes, and we have had some interesting adventures. We have fished for largemouth and smallmouth bass in remote areas of Canada and Maine, hunted for permit fish, and used sight fishing (with a permit) to catch barracuda in the Florida Keys. We once launched a boat on train tracks and pushed in two miles to a lake and camped on an island. We have cleaned lines by fireside and lost poles in the middle of the ocean. Sharks have eaten our catch while we were reeling it in.

I have been bitten by many pike, and Jim has gutted many walleyes. We have caught sunfish and blue gills with simple hooks, lines, and our hands. We have fly-fished in parts of the world to which few people ever travel. Although we have some unique fish stories, we used that time to talk about everything from medicine to hopes and dreams, politics and prose. We try to find joy and humor in as much of life as we can. We hope you are able to do the same in your time away from the bedside. The best fish story is always the one that got away. Thanks for reading!

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Monday, August 3, 2020

​Certain emergency department procedures bring us a sense of accomplishment. We cheer after a shoulder returns to its correct position from our relocation technique and smile when a laceration closes just right. Emergency department procedures can be very rewarding for providers and patients, especially during times of stress in the workplace. Sometimes, just stapling a scalp or molding the perfect splint may seem cathartic. There are days where we can only see so much abdominal and chest pain—and COVID-19.

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The double-person Quigley maneuver technique for an ankle fracture. Photo by Martha Roberts.

This month we want to show you a special procedure mastered by our orthopedic colleagues. As we discussed last month, trimalleolar fractures of the ankle are painful, troublesome, and unstable. Quick and simple reduction and temporary splinting of these injuries are important ED procedures in preparation for transfer or surgery. These fractures often require advanced imaging and always require surgery. This is a temporary procedure to stabilize the ankle before surgery, which is typically done the next day.

Ankle fractures can be tricky and occasionally need conscious sedation. But if you premedicate a patient with oral ibuprofen, acetaminophen, and possibly oxycodone and do a hematoma block in advance, you may be able to reduce a trimalleolar fracture without sedation. This may be particularly useful during the pandemic when resources may be light and airway procedures should be limited.

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Trimalleolar fracture in the distal tibia and fibula.

This case involved a young man with a trimalleolar fracture of the left ankle. The fracture included the lateral, medial, and the distal posterior aspect of the tibia, known as the posterior malleolus. Our post last month discussed the case in detail and provided an overview of trimalleolar fracture and ankle hematoma blocks. Orthopedics came to the ED to assist with the reduction using the Quigley maneuver.

The Quigley Maneuver

This maneuver requires two people, sometimes three. It can be modified, but the same principles apply: knee flexion, which relaxes the gastrocnemius-soleus complex, external rotation of the lower leg, and simultaneous foot adduction and supination. Watch a demonstration of this in the video below.

The key is relaxing the gastrocnemius-soleus complex, which also relaxes the Achilles tendon. Having a partner bend the patient's knee while you perform traction techniques is the easiest way to do this. When you pull up on the big toe of the injured extremity, the foot naturally rotates internally and the leg naturally rotates externally.

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The triple-person Quigley maneuver technique for an ankle fracture prior to surgery. Photo by Martha Roberts.

After you complete the reduction, apply a stirrup or sugar-tong splint with a short posterior leg splint for reinforcement to stabilize the injury before transfer or surgery. Learn more about lower leg splints in our post from last year: https://bit.ly/3fCfipO.

A modified single-person Quigley maneuver can be done in two ways. The first technique involves the provider bending the patient's knee and dorsiflexing the foot by pulling on the toe, internally rotating the foot and externally rotating the lower leg. This is also shown in the video below. You can also place a stockinette over the injured leg and hang the foot in traction using an IV pole or weighted stand. This negates the need for a second person, although a nurse or technician can help with this maneuver, and it should rarely have to be done alone.

Make sure you have web rolls, ACE wraps, and other splinting materials available before you start. Do not wet the splinting material until completely ready to apply. Place a bin of water on a side table, and dip the plaster or fiberglass splint when appropriate. If you find that the stockinette keeps becoming displaced while hanging in traction, add tape or an ACE bandage around the more proximal site. Also place a bolster under the patient's thigh and neck to help support the natural curvature of the body.

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Watch a video of the Quigley maneuver.

The Approach

The Quigley maneuver to reduce ankle fractures prior to surgery.

The Pause

Radiographs should be taken above and below the site of the injury, including AP, lateral, and oblique films of the ankle and of the tibia, fibula, and foot. Confirm with orthopedics and radiology as needed.

The Procedure

  • Premedicate the patient. If you are not doing moderate sedation, consider administering a combination of 600 mg of ibuprofen and 1000 mg of acetaminophen with or without 5-10 mg of oxycodone. You may also consider initial IV placement instead. A single dose of ketorolac, morphine, or fentanyl is acceptable.
  • Consider using an ankle hematoma block, which was featured in last month's post. When done correctly, it allows for an incredibly smooth reduction and avoids further sedation.
  • Gather all equipment in advance, including splinting material such as plaster or fiberglass, a water bin, ACE wraps, and web rolls.
  • Lay the patient supine and support his neck with a pillow or blanket because the natural curvature of the body when you flex the knee will make him want to sit up slightly.
  • Support the thigh on the affected side with a bolster, pillow, or blanket, and bend the knee, relaxing the gastrocnemius-soleus complex and Achilles tendon.
  • Using both hands, internally rotate the foot. This causes the lower leg to rotate externally.
  • Use traction and countertraction techniques as noted in the video.
  • Complete the reduction and confirm with bedside fluoroscopy and post-reduction films. Check out our prior posts on using fluoroscopy in the ED. Orthopedic consultants commonly assist with this procedure.
  • Hold the foot in dorsiflexion and apply the splint. We also show this in the video.
  • Consider a stepwise approach in applying the splint: Wrap the lower leg and ankle starting distally, moving more proximally. If using plaster, use the web roll on the side that will be touching the ACE wrap. Fiberglass comes precoated with a soft material similar to that of a web roll. Use an ACE wrap for the outer layer.
  • Always check neurovascular status and let the material dry completely before allowing the patient to move around or dangle his leg.

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Jim weighs in

  • Always consult orthopedics before completing this procedure in the ED because they may take the case right to the OR.
  • If surgery is not immediate, consider IM or IV opioids.
  • Note that these patients are admitted to the hospital or transferred.

Martha weighs in

  • The stirrup or sugar-tong splint goes on first, and the posterior short splint goes on second.
  • Mold with flat hands; do not dent the plaster with pointy fingers. Place one hand above the fracture and the other below while molding. You can use your chest or shoulder to help with the pressure of molding (see photo above). Leaning into the patient using your body weight is useful.
  • Web rolls and orthopedic residents are your friends.