UMEM Educational Pearls - Visual Diagnosis

The image shows air bubbles in the anterior chamber. Since air has been introduced into the eye, the patient is at risk for elevated intraocular pressures. In addition, you would need to consider endophthalmitis as a complication.

Answer: Talar dislocation

Below, a post-reduction Xray, as well as a link to a video demonstrating a few ankle reductions (the video's background music makes all the difference): http://www.youtube.com/watch?v=AzqCsLX1K1E

Follow me on Twitter (@criticalcarenow) or Google+ (+haney mallemat)

Herpes Zoster

Answer: Right ventricular (RV) dysfunction secondary to submassive pulmonary embolism (PE).

Ultrasound for suspected PE

Consider bedside echo with PE and elevated troponin or BNP.

Recall the classes of PE:

1. Non-massive PE: Normal RV function with normotension
2. Submassive PE: RV dysfunction (see below) with normotension
3. Massive PE: RV dysfunction with hypotension
4. Cardiac arrest (Pulseless electrical activity)

Ultrasound “clues” of submassive / massive PE:

1. Right ventricular enlargement: RV diastolic volume is >60% of the LV; normally  RV is 60% the size of the LV.
2. Interventricular septal shift ("D-sign"): The normally concentric LV cavity will now look like the letter “D” from diastolic septal flattening; "D" sign indicates elevated pulmonary pressure (e.g., pulmonary embolism)
3. McConnell’s sign: Hypokinesis in RV free wall with normal apical motion; originally though to be specific for PE, but sensitivity and specificity have been questioned because other disorders also have a "McConnel'-type" appearance (severe pulmonary hypertension, RV infarction); can still help add to pre-test probability.
4. Free-floating thrombus: clot visualized in pulmonary artery and/or in right-side of heart (rare)

Lodato JA, Parker Ward RP, Lang RM. Echocardiographic Predictors of Pulmonary Embolism in Patients Referred for Helical CT. Echocardiography 2008;25:584-590.

McConnell MV, Solomon SD, Rayan ME, et. al. Regional Right Ventricular Dysfunction Detected by Echocardiography in Acute Pulmonary Embolism. Am J Cardiol. 1996; 78: 469-473.

ACEP. Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Pulmonary Embolism. http://www.acep.org/content.aspx?id=30060. [July 24, 2011].

John Griffiths. Respiratory: Management of small, submassive and massive pulmonary embolism. http://www.frca.co.uk/article.aspx?articleid=100750. [July 24, 2011].

Follow me on Twitter (@criticalcarenow) or Google+ (+haney mallemat)

Answer: Monteggia fracture

Monteggia Fracture

• Ulnar fracture with dislocation of proximal radioulnar joint (often subtle); do not confuse with Galeazzi fracture (radial-shaft fracture with distal radioulnar dislocation)
• Due to fall on outstretched hand with arm in hyper-pronation or with direct trauma to forearm as in defensive wounds (e.g., nightstick injury).
• Ulnar fracture typically the proximal third (although any portion can be involved).
• Relatively uncommon; 1-2% forearm fractures
• Interosseous membrane (between radius and ulna) transmits forces to radioulnar joints and causes associated dislocations.
• Suspected forearm fractures should always include Xray of the wrist, forearm, and elbow  
• Bado classification system (Type I-IV) used; based on displacement of radial head.
• Children may be treated with closed reduction and immobilization; adults usually require open reduction and internal fixation.
• Radial head dislocations should be reduced within 6-8 hours as can lead to articular damage and/or nerve injury.
• Radial, ulnar and/or median nerve neuropraxias (motor or sensory deficits) may complicate injury with resolution over several weeks.

Bruce H.E., Harvey J.P., Wilson J.C. Monteggia Fractures. J Bone Joint Surg Am. 1974;56:1563.

Reckling F.W. Unstable fracture-dislocation of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am. 1982;64:857.

http://emedicine.medscape.com/article/1231438-overview
 

Follow me on Twitter (@criticalcarenow) or Google+ (+haney mallemat)

Answer: Lung Abscess (from septic pulmonary emboli)

Lung Abscess

• Necrosis of lung parenchyma with pus and debris-filled cavities

• Caused by direct injury (e.g., aspiration pneumonia) or secondary causes (e.g., tricuspid  endocarditis, bacteremia, etc.)

• Suspect with:

  • Loss of airway reflexes (e.g., CVA, seizures, alcohol / narcotic abuse, etc)

  • Poor dentition

  • Immunosuppression

  • IVDA

• Gram positives, negatives and anaerobic bacteria have all been implicated.

• CXR may suggest diagnosis, but CT scan better identifies abscess, necrotic tissue, empyema, or other pathology (see image below).

• After drawing blood cultures, broad-spectrum antibiotics should be started and narrowed once culture data is available; address underlying cause (e.g., valve replacement for endocarditis).

• Prognosis is generally good with normal immune function and antibiotics, but mortality sharply increases with immunocompromise and treatment delay.

Mansharamani N, et al. Lung abscess in adults: clinical comparison of immunocompromised to non-immunocompromised patients. Respiratory Medicine. Mar 2002;96(3):178-85

Follow me on Twitter (@criticalcarenow) or Google+ (+haney mallemat)

Answer: Calcaneus fracture; historically called the “Lover’s Fracture” for “lovers” jumping out of bedroom windows to evade suspicious spouses and landing directly on their feet.

Calcaneus fractures

• Most commonly fractured tarsal bone
• 2 types:
  • Extra-articular fracture from direct blow, twisting force and repetitive forces (causing stress fractures)
  • Intra-articular fracture from axial loading secondary to fall >6 feet, motor vehicle crash, etc; this is the classic “lover’s fracture”
• 10% of axial loaded intra-articular fractures associated with:
  • Bilateral calcaneus fractures and/or,
  • Thoracic or lumbar compression fractures and/or,
  • Proximal femur or tibial plateau fractures
• Ankle Xray is diagnostic for fractures and to measure Bohler’s angle (angle formed by intersection of lines connecting apex of anterior process with the apex of posterior facets and apex of posterior facet with the posterior tuberosity; see figure below)
  • Normally 20-40 degrees; <20 degrees increases suspicion for intra-articular fracture
• Ankle CT in select cases; Xray may underestimate some injuries
• Typically, extra-articular fractures treated with closed reduction and casting, while intra-articular fractures by open reduction and internal fixation (closed reduction in select cases)

Rosen's Emergency Medicine: Online Edition

Follow me on Twitter @criticalcarenow

Answer: Steven-Johnson Syndrome

French LE. Toxic epidermal necrolysis and Stevens Johnson syndrome: our current understanding. Allergol Int. Mar 2006;55(1):9-16

Schöpf E. Toxic epidermal necrolysis and Stevens-Johnson syndrome. An epidemiologic study from West Germany. Arch Dermatol. 1991;127(6):839.

Roujeau JC. Severe adverse cutaneous reactions to drugs. N Engl J Med. 1994;331(19):1272.

Follow me on Twitter @criticalcarenow

Answer: Scapular Fracture

Scapular Fracture

• Uncommon (1% of all fractures)

• Extensive force required; high probability of associated injuries (pneumothorax, shoulder dislocation).

• 5 types: body/spine, acromion, neck, glenoid, and coracoid

• Arm held in adduction and pain with shoulder movement; may mimic rotator cuff tear.

• Obtain X-rays (AP shoulder and lateral scapula) or CT (if displaced).

• Conservative management for non-displaced fractures; Orthopedic reduction for displaced fractures.

• Complications include post-traumatic arthritis or bursitis.

• NSAIDs are first-line analgesics.

Rosen P, Barkin R. Emergency Medicine: Concepts and Clinical Practice. Mosby Year Book; 2010:573-574.

Zlowodzki M, Bhandari M, Zelle BA, Kregor PJ, Cole PA. Treatment of scapula fractures: systematic review of 520 fractures in 22 case series. J Orthop Trauma. Mar 2006;20(3):230-3.

The x-ray shows air in the soft tissue of the right neck and supraclavicular area. Close inspection of the mediastinum reveals subtle air along the heart border. Diagnosis: pneumomediastinum.

Often the first clue of pneumomediastinum is air in the neck and supraclavicular area on plain film. So, always look at the soft tissues on chest x-ray.

Answer: Tri-plane ankle fracture

Tri-plane Fractures (Submitted and written by Dr. Michael Santiago)

• Multi-planar ankle fracture in older children and adolescents during an 18 month window prior to distal tibial-physis closure.
• 3 planes (see Xray below): coronal (A: tibal metaphysis), sagital (B: epiphysis), and transverse (C: growth plate)
• Associated fibular spiral fracture (50% cases)

• Commonly due to external rotational or "twisting" forces.
• Xrays are helpfully, but CT scan may be indicated as fractures may be more displaced than radiographs suggest.
• Non-operative treatment for non-displaced fractures:
  • Closed reduction with long-leg splint/cast
  • Reduction may slip once swelling has subsided
• Indications for operative repair:
  • >2mm displacement of fracture segments
  • Intra-articular fracture

Acalculous Cholecystitis

Diagnosis: Mandibular Dislocation

The link below demonstrates an interesting alternative to the traditional reduction method; prospective randomized trails are pending.

http://www.youtube.com/watch?v=Kp8AzHIC0hM

Thanks to Dr. George Kochman for the image and Dr. Christopher Doty (EM Program Director at SUNY Downstate / Kings County Hospital Center) for the video.

Ogilvie's syndrome / Acute colonic pseudo-obstruction (ACPO)

Fazel A, Verne GN.  New solutions to an old problem: Acute colonic pseudo-obstruction. JClin Gastroenterol 2005; Vol 39(1): 17-20.

Ozkurt H, Yilmaz F, et al.  Acute colonic pseudo-obstruction (Ogilvie's syndrome): radiologic diagnosis and medical treatment with neostigmine.  Report of 4 cases.  Am J of Emer Med 2009; Vol 27: 757.e1 - 757e4.

Yes...the shoulder is dislocated, but did you notice anything else? (see figure 1)

Glenoid Fossa Fracture: (Image submitted by Dr. George Kochman)

Fractures of the glenoid fossa occur when the head of the humerus collides with the glenoid margin; classically, by a laterally directed force. Although less than 10% of glenoid fossa fractures result in significant displacement, surgical repair is indicated if: 

• Fracture displacement >10mm
• >33% involvement of posterior glenoid fossa
• >25% involvement of anterior glenoid fossa
• Persistent humeral head subluxation

Schmidt, J. Scapular Fracture. eMedicine. January 12, 2011.

http://emedicine.medscape.com/article/826084-overview

Durant, A.  Nagdev, A. Ultrasound detection of Lung Hepatization. West J Emerg Med. 2010 September; 11(4): 322-323.

Ectopic Pregnancy Pearls

1. Considering the history above, transvaginal ultrasound should be performed regardless of quantitative beta-HCG; even if below the discriminatory zone (<1500-1800)
2. Transvaginal ultrasound suggests ectopic pregnancy (as in the case above), with an empty uterus and free pelvic fluid (Figure 1).
3. The above history plus free abdominal fluid on FAST exam also suggests the diagnosis and should expedite management (Figure 2). 
4. Please remember that ~15% of ectopic pregnancies present with normal menses.

Tintinalli, Judith, et al.  Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide, 7^th Edition.  2011, McGraw-Hill Companies, Inc, China

Luxatio Erecta-inferior glenohumeral dislocation
 

A rare shoulder dislocation caused by a hyperabduction injury to the arm.

Many thanks to Dr. George Kochman for submitting this case!