A Perpetual Red Flag
As I looked over my patient's elbow images, he asked, "Is it terrible?"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...
Source: Lions and Tigers and Bears - July 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Tracing an Ankle Injury by Type
"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?"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 fractureTrimalleolar fracture equivalentAn exorotation fracture, likely supinationThe 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 ...
Source: Lions and Tigers and Bears - June 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Pain from an Unknown Cause
"My left hip has been hurting for a couple years, but it just got really bad in the past few weeks."My patient, who was in her 70s, didn't add much more to the history. No trauma. No fevers. No bowel or bladder problems. No significant past medical history. Her hip just hurt. She thought she needed an x-ray, and one was obtained.The left femoral head didn't look terrible. There was some irregularity, but there were no fractures or significant joint narrowing. This wasn't a case of neglected severe degenerative joint disease or avascular necrosis that needed a hip replacement.Some red flags started to show up t...
Source: Lions and Tigers and Bears - May 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Watch This Space
I am relatively new to working with our advanced practice practitioners, so I often check x-rays if I have a moment.An x-ray of a wrist has a great chance of being reviewed because this is my favorite joint. I love the challenge of catching things when I don't know the case. I was definitely rewarded by this case.The thing that caught my eye was the space between the scaphoid and the lunate. It was huge, especially when looking at the sclerotic changes in the other bones of this wrist. Most of the joint spaces seem narrowed but not the scapholunate. Whether you go with the British version (Terry Thomas) or the American ...
Source: Lions and Tigers and Bears - April 1, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Not Alone
"Hey, what do you think of this? It isn't dislocated, but this guy was in a fight, and has a lot of shoulder pain," a colleague said to me.It seems that the humerus gets virtually all the attention in shoulder x-rays, particularly in the Y view. Many are done with the image after determining the head truly sits in the middle of the Y between the coracoid and the acromion. There is more to shoulder films than just the humeral head's location, however. Take another look at the coracoid and the acromion.Scapular fractures account for just one percent of fractures. The vast majority of these are of the body and th...
Source: Lions and Tigers and Bears - March 2, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Air with Nowhere to Go
I have been writing this blog for nearly six years, and my curiosity and pleasure in reviewing interesting, unusual radiographs are widely known among my colleagues. On a recent shift, a friend brightened on seeing me and exclaimed, "I want you to take a look at this!" She immediately opened PACS to this image."What's the story?""An elderly lady had a mechanical fall at home, coming down on her right shoulder.""What do you think?" I asked, glancing at my med student."The joint looks too close. There is a lot of DJD. I can't tell if there is a fracture.""Yes, but loo...
Source: Lions and Tigers and Bears - January 31, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Classic Fist Fight Injury
A right-handed man presented with swelling and tenderness at the base of his thumb after an altercation. His range of motion at the metacarpal-carpal joint was limited because of pain. Not unexpectedly, his first metacarpal was broken. What can you tell this patient about his injury?You can say:This fracture has a name: Bennett's fracture.It is the most common fracture of the base of the thumb.His fracture is classic in mechanism; fist fights commonly produce this injury (by having an axial load against a partially flexed first metacarpal).His radiographs are classic in appearance—a two-piece intraarticular fr...
Source: Lions and Tigers and Bears - January 2, 2020 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Screwed (Literally)
I looked over the list of patients waiting to be seen as I started my evening shift. I was the coverage doctor for the advanced practice practitioners, so I also checked the fast track charts when I saw "screw in finger."Having some ideas, I quickly went to find a man who had been doing some home repairs when his battery-operated screwdriver skipped, causing him to drive the screw into his left index finger.The patient had tried to unscrew it himself, but it was too painful. After convincing him a digital block would provide pain relief, other options were considered:Backing the screw out with a battery-po...
Source: Lions and Tigers and Bears - December 2, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Three of Four
I went immediately to the coronal slices when I opened the CT images. I was looking for something specific. This image made me smile. (See below.)It confirmed my clinical suspicion. "Three of four isn't bad," I said to the resident who looked at me blankly and asked, "Three of four what?""Three of four radiographic signs of orbital blowout fractures," I said.Then I felt really old. That was a thing when we used plain films to make the diagnosis and read them ourselves. The regular quiz at the weekly conferences had drilled it into me. I had to know this or suffer the embarrassing consequences....
Source: Lions and Tigers and Bears - November 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Ping Pong Balls in the Lungs
"She's worried I had a heart attack."That was the answer I got from the 70ish-year-old patient pointing at his wife when I asked why he came to the emergency department. She quickly added, "He had terrible pain four days ago on the right side, and now he gets winded when he walks."I had already seen his ECG, so I assured her that it appeared normal. I was going to order a chest x-ray, however, because his lungs sounds were pretty quiet. She said he had COPD, and wanted to know if he needed an inhaler.The last time I had seen something like this was in medical school 30 years ago. At that time, I was ...
Source: Lions and Tigers and Bears - October 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Lunate That Died
Everyone who works with me knows that I love joint radiographs, and the wrist is my favorite. It was no surprise when I came on shift that someone exclaimed, "I have an x-ray for you. I bet you will know exactly what it is! This 30-ish-year-old lady came in with atraumatic wrist pain."I did know exactly what it was. My eyes were drawn to the lucent lunate target. The patient was still in the ED, so I went to examine her hand. She had increased pain when I walked my fingers proximally down the metacarpal, which dipped into the carpal space. She was also not a fan of volar flexion or dorsiflexion. It made sense....
Source: Lions and Tigers and Bears - September 3, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
A Classic Pediatric Fracture
"I have an 8-year-old who fell on the playground and now has elbow pain. Can you look at the x-ray?""Of course! Is it a supracondylar fracture?"Interrupting the pregnant pause, I cautioned, "You know, at the elbow, adults tend to break the radial head. Kids, on the other hand, usually break the supracondylar. A boy under 10 with a fall and hyperextended with an outstretched arm is likely supracondylar. The olecranon comes through the weakest link—the narrow part of the elbow's figure eight."When the lateral popped up on the screen, it was classic, showing the four signs of a supracondylar...
Source: Lions and Tigers and Bears - August 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Weak Links
"Can you look at a knee film?""Sure, what is the issue?" I was the coverage doc for Fast Track."It's a 15-year-old who hobbled in here with knee pain. Just before coming in, he was in football practice where he forcefully hyperextended his knee and heard a pop. Since then, he hasn't been able to bear full weight on the leg. He pointed to the fibular head area as the point of maximal pain. What do you think of the fibular head, and is that oval in the femur anything?""The femur oval is likely a benign bone cyst. The fibular head is probably OK, but it is a kid with growth plates. It is ...
Source: Lions and Tigers and Bears - July 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
One for the Win Column
"The lab called with a critical value on the woman in bed 12. Her hemoglobin is 4.8," the nurse said.That didn't make any sense. The patient didn't look anemic or pale. She didn't seem to have symptomatic anemia. Maybe she had heavy periods."Do you want a type and cross?" the nurse asked."No, I can't believe that is right. Can you draw a new CBC? I'm going back to see her again," I replied.Thirty minutes later, the EMR showed the labs were back. There was no exclamation mark indicating something was amiss, and here's what I saw when I clicked the box. "The hemoglobin's normal—13...
Source: Lions and Tigers and Bears - June 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
How Low Did He Go?
At sign-out, I thrust this VBG at my oncoming colleague.Me: What do you think of this?Colleague: 6.76. That is pretty low. DKA?Me: Nope, the sugar was 107.Colleague: Post code?Me: Not that either.Colleague: Did you intubate him?Me: No, I was scared that would kill him with a worsening acidosis if we don't get his respiratory rate fast enough.Colleague: Did he go to the ICU?Me: He went to tele.Colleague: What made him better?Me: Fluids and midazolam. A lot of midazolam—5 mg IM followed by 15 mg IV. He was brought in crazy agitated after a first-time seizure. I thought he...
Source: Lions and Tigers and Bears - May 1, 2019 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
