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Answer radER vol. 1.5

radER Winners:

David Mishkin

Allison Loynd

Answer to Case 1.5

A 56-year-old man was brought to your ED after bring involved in a MVC.  He was a restrained driver in a car that was traveling at 40 MPH and slammed into a tree.  The patient denies loss of consciousness.

1.  When examining anyone with a complaint of ankle injury it is important to exam and document the 5 following areas:

  • Proximal fibula
  • Medial malleolus
  • Lateral malleolus
  • Proximal 5th metatarsal
  • Navicular (medial margin of the midfoot)

2.  The x-rays reveal the following findings: Proximal fibula spiral fracture, avulsion fracture off the medial malleolus and a non-displaced posterior malleolar fracture

3.  The patient should be splinted using a sugar-tong posterior mold technique, be placed on crutches, instructed to be non-wt. bearing, ice, elevation, provided pain medication and discharged with orthopedic follow-up within a week.  This is a potentially unstable ankle injury that may need surgical care.  This point should be emphasized to the patient who should be non-weight bearing until evaluated by the orthopedist.

special-comment-3

A proximal fibular shaft fracture that occurs in association with an ankle injury is termed a Maisonneuve fracture.  Its clinical significance is that, in most cases, it is indicative of disruption of the distal tibiofibular joint — an unstable ankle injury that usually requires surgical care – stabilization with a screw through the distal tibiofibular joint – a syndesmosis screw.  The mechanism of injury is external rotation of the foot relative to the lower leg.  Rotation of the talar dome within the ankle mortise splits apart the bones and ligaments of the ankle.  In most cases, the torsional force at the ankle produces a distal fibular (lateral malleolar) fracture.  In some cases, the lateral injury occurs proximally – the Maisonneuve fracture.

In this patient, there are both medial and posterior fractures, but no lateral injury at the ankle, which is suspicious for a Maisonneuve fracture.  This should prompt ordering radiographs of the entire tibia and fibula.  However, the distal tibiofibular joint space is not widened.  Therefore, prior to deciding on surgical care, the orthopedist will perform stress views of the ankle to ascertain whether or not the distal tibiofibular joint is intact.

A Maisonneuve fracture should be suspected when there is a medial ankle injury (medial malleolar fracture or deltoid ligament tear), or disruption of the distal tibiofibular joint (widening of the space between the distal tibia and fibula on the mortise view), or a “posterior malleolar” fracture (posterior lip of the distal tibia), and no lateral malleolar fracture.  The patient may complain only of pain at the ankle, not knee or lower leg, which is why the proximal fibula and fibular shaft should be palpated in all patients with ankle injuries.

When to Suspect a Maisonneuve Fracture

  1. Medial malleolar fracture or deltoid ligament tear (wide medial joint space) without a distal fibular fracture
  2. Widening of the distal tibiofibular joint without a distal fibular fracture.
  3. Tenderness over the proximal fibula in a patient who has sprained their ankle – ankle radiographs may be normal.
  4. Displaced fractures about the ankle, including distal fibular fractures, when there is tenderness over the proximal fibula. Some authors recommend radiography of the entire fibula in all patients with displaced fractures about the ankle.

image-11Figure:  External rotation of the foot relative to the leg splits apart the ankle mortise.  The force of injury on the lateral side is transmitted up to the proximal fibula.  The interosseous ligament (asterisk) usually remains intact.

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References

Lock TR, et al: Maisonneuve fracture: Case report of a missed diagnosis.  Ann Emerg Med 1987; 16:805-807. Del Castillo J, Geiderman JM: The Frenchman’s fibular fracture (Maisonneuve fracture). JACEP 1979;8:404-406. Schwartz DT: Emergency Radiology: Case Studies, McGraw-Hill, 2008, pp. 301-306.Pankovich AM:  Maisonneuve fracture of the fibula.  J Bone Joint Surg 1976;58A:337-342.  Duchesneau S, Fallat LM: The Maisonneuve fracture. J Foot Ankle Surg  1995 ;34:422-428.Hensel KS, Harpstrite JK: Maisonneuve fracture associated with a bimalleolar ankle fracture-dislocation. J Orthop Trauma 2002;16:525-528.Babis GC, Papagelopoulos PJ, Tsarouchas J, et al: Operative treatment for Maisonneuve fracture of the proximal fibula. Orthopedics 2000;23:687-690.

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.  Special Comment is provided by Dr. David Schwartz, Associate Professor of Emergency Medicine at NYU/Bellevue Hospital Center and author of two emergency radiology textbooks.

Answer VizD 1.5

Case 1.5

VizD Winners

Brian Kern                      Chris Guyer                Rob Klever

Scott Ottolini                  Devon Moore             David Mishkin

Kevin MacWilliams          Marjan Siadat             Allison Loynd

A 53-year-old woman presents to your ED after tripping down a flight of steps. On exam, you note marked swelling of her right orbit with proptosis of the right eye. You ask the patient to look to the side but she cannot move her eye.

Questions:
1. What is the procedure being performed?
2. What is the most common reason to perform the procedure?
3. What complication are you trying to prevent in performing this procedure?

Answer:

This week, Dr Susi Vassallo, author of the seminal work on emergency canthotomy, and previous EM resident at Detroit Receiving Hospital, will discuss the answer to this weeks VizD

Receiving: When indicated, why is it so important to perform a lateral canthotomy?
Dr Vassallo: Performance of lateral canthotomy is critical to decompression of the orbit and relief of pressure on the optic nerve. Otherwise, there is risk for ischemia to the optic nerve resulting in blindness.
Receiving: In your opinion, what is the most important technical aspect in performing this procedure?
Dr Vassallo: The most important technical aspect in performing the procedure is palpating the lateral canthal tendon and cutting it. It is more easily palpated than visualized.
Receiving: How often do you see this procedure performed? (no pun intended)
Dr Vassallo: This procedure is performed more often than one would think. When I first wrote this article, Dr. Peter Rosen, then editor of the Journal of Emergency Medicine did not think it was an emergency medicine procedure. We happened to be talking years later when Dr. Rosen was practicing in Jackson Hole Wyoming. He told me that one of his former residents had to perform the procedure without ophthalmology assistance; this is when he realized it was important for emergency physicians to understand the indications for the procedure and to know how to do it.
Receiving: How does it feel that Roberts and Hedges Procedure book uses your article and images for their chapter on lateral canthotomy?
Dr Vassallo: I am happy to see the pictures from our article in the book by Roberts and Hedges. Jim Roberts is one of my hero clinicians.
Receiving: Thank you for your time!
Dr Vassallo: Of course, you are very welcome!

Check out Dr Vassallo’s article

Here is video of the actual procedure

Thank you to everyone who submitted their answer.  Stay tuned for next week’s VizD

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

radER vol. 1.5

Case 1.5

A 38-year-old man was playing basketball when he came down from a rebound and twisted his right ankle.  He complains of pain to his right lower extremity and is unable to bear weight on his ankle.  You provide him an ice pack, pain medication, and obtain the following radiographs.

1.  Name 5 areas that should be examined and documented in the medical record?

2.  Describe the radiographic findings?

3.  Describe the treatment and disposition for this patient?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.  Special Comment is provided by Dr. David Schwartz, Associate Professor of Emergency Medicine at NYU/Bellevue Hospital Center and author of two emergency radiology textbooks.

VizD Vol 1.5

Case 1.5

A 53-year-old woman presents to your ED after tripping down a flight of steps. On exam, you note marked swelling of her right orbit with proptosis of the right eye. You ask the patient to look to the side but she cannot move her eye.

Questions:
1. What is the procedure being performed?
2. What is the most common reason to perform the procedure?
3. What complication are you trying to prevent in performing this procedure?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

Interview: Dr. David Newman

dr-newman

Dr. David Newman is the Director of Clinical Research and Assistant Professor in the Department of Emergency Medicine at St. Luke’s-Roosevelt Hospital Center/Columbia University in New York City.  In 2005, as a major in the army reserve, he was deployed to Iraq, where he received an Army Commendation Medal.  Dr. Newman recently published the book, Hippocrates’ Shadow: Secrets from the House of Medicine.  In this page-turner, Dr. Newman reviews research that refutes common and accepted medical wisdom. He cites studies that show how mammograms may cause more harm than good; why antibiotics for sore throats are virtually always unnecessary and therefore dangerous; how cough syrup is rarely more effective than a sugar pill; the power and paradox of the placebo effect; how statistics and studies themselves are frequently deceptive; and why CPR is violent, invasive — and almost always futile.  In addition to his penchant for writing, Dr Newman is a dedicated teacher and passionate clinician.

Receiving: What inspired you to write Hippocrates’ Shadow?

Dr. Newman: Hippocrates’ Shadow has been burning inside of me since medical school. My sense, in fact, is that it’s a book that’s been burning inside most doctors. It gives voice to a growing reality in medicine: the deepening divide between outsider and insider. On both sides of the stethoscope we frequently misunderstand the science of medicine, and in some cases we all seem to have forgotten its purpose. The book is an attempt to reconcile those two roles through transparency, to understand the science of medicine more completely, and to find a universal thread in our dualities — science and society, doctor and patient.

Receiving: Was Hippocrates the ideal physician?

Dr. Newman: Prior to the teachings of Hippocrates, physicians on the Greek island of Kos (where Hippocrates was raised and ultimately taught medicine) practiced in the ‘Aesculapian’ tradition. This was a mystical form of healing in which patients were brought to a sacred Aesculapian temple, given ‘medicinal’ sedative substances, and upon wakening asked to recall their dreams. These dreams were felt to be the key to their recovery, carrying messages that were to guide the healing regimens that followed. Hippocrates was unique in undertaking a more scientific approach. He documented his patient encounters assiduously, categorized the illnesses he witnessed, and was fanatical about recording and learning from his empiric observations. This was new. What is fascinating about him, and what appears to have endeared him to his peers around the world, was his ability to respect the power and traditions of the mystical while championing the power of the scientific.

To put it in classic philosophical terms, in medicine we have chosen logos (measurable fact) over mythos (tradition and emotion). Given the advances in our knowledge over the last century, and tremendous strides in technology, this makes sense to us. But our nearly blind faith in science has led us, in many cases, to ignore the data that our science generates. Hippocrates’ Shadow explores areas that are difficult for physicians to reconcile with the content and tone of our education, including the surprising limits of our knowledge, the profound and proven impact of placebos and mind-body connections, and the overuse, imprecision, and inaccuracy of most x-rays, EKG’s, and other tests. To discover these areas as a physician is humbling, and empowering. Hippocrates fused these two worlds in a way that maximized benefit for his patients. His ability to do this was very much the ideal that we should be striving for.

Receiving: You are an Army Reservist, how did your time spent in Iraq influence the way you practice Emergency Medicine

Dr. Newman: Combat medicine certainly impacted my practice, and it probably will for the rest of my career. Defining that impact is tricky because it’s more mental than practical. What struck me most about the experience was the sense of how unique a physician’s position is in a combat zone. The job of healing and tending without prejudice—to any and all comers—transcends the enmity and the violence of war. That’s a special gift and a privilege, and it gave me a real respect for how special our job is.

Receiving: Your book presents convincing evidence that some routine medical screens, such as mammography, colonoscopy, and PSA level, does not improve patient outcome.  Have you received any backlash for these statements?

Dr. Newman: Only those who haven’t read the book seem to object, at least so far. I try in the book to use plain language to untangle many of the statistical walls that have, I believe, made understanding data on these interventions difficult. Once these walls are gone the implications of the data become fairly clear. In the case of mammograms the existing evidence is strong, and it indicates that there is no identifiable life saving benefit to mammography as a screening tool in unselected populations. That’s something that most patients and most physicians aren’t aware of. What examples like this point out is that we have, in many cases, ignored scientific evidence in support of our science, and we continue to do so every day. The irony is hard to miss, and it’s a recurring theme in the book.

Receiving: You are the Director for Clinical Research at St-Lukes Roosevelt Hospital/Columbia University; is Emergency Medicine making a statement in medical research?

Dr. Newman: Emergency medicine is the frontier for innovative clinical research. As I point out in Hippocrates’ Shadow, the structure of our science means that on an individual level our greatest impact comes in the case of patients who are the most acutely ill, often at the earliest moments of their illness. Interventions like trauma surgery, and early goal directed therapy, and treatments for MI and cardiac arrest are all examples of how powerful our field, and research in our field, can be. The National Institutes of Health, the AHRQ, the CDC, and other major funding agencies are all beginning to catch on to this fact. As medicine begins to find itself and to value its most important resources many of the interventions with the greatest impact on human health will be developed and researched in emergency departments.

Receiving: Who is your role model?

Dr. Newman: Hippocrates, of course.

Receiving: What book are you currently reading?

Dr. Newman: ‘Sick’, by Jonathan Cohn, a brilliant, case-based chronicle of our health care system’s history and current state.

Receiving: Is a second book in the works?

Dr. Newman: I’m not sure yet. There certainly are many ideas swimming around in my head, but for now I’m going to work on getting the message of Hippocrates’ Shadow out.

Receiving: Thank you for your time.

Dr. Newman: My pleasure.

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Hippocrates’ Shadow: Secrets from the House of Medicine

“The Meeting Room” is devoted to interviewing leaders in Emergency Medicine.  Please email me with suggestions on people you would like to see interviewed or if you would like to conduct an interview.

Law and Medicine: November

By Dainius A. Drukteinis, M.D., J.D.

“The only real mistake is the one from which we learn nothing.”
– John Powell


Timing in the Emergency Department

From a patient care standpoint, as well as a liability standpoint, the timing of interventions in the Emergency Department is often crucial. In medical malpractice cases, plaintiff’s attorneys highlight unduly long periods of time for critical treatment, and juries may be unsympathetic to prolonged delays. In an Emergency Department bursting with patients, the allocation of time is one of the greatest challenges for the emergency medicine physician.

In O’Shea v. State of New York, 2007 N.Y. Misc. LEXIS 386, a patient presented to an Emergency Department having cut off two fingers with a table saw. The injury occurred at 6:30 p.m. The patient was triaged at 7:19 p.m. The emergency medicine physician saw the patient at 7:42 p.m. X-rays were performed at 11:33 p.m. Orthopedics was finally consulted at 1:00 a.m., more than five-and-a-half hours after the patient presented to the Emergency Department. Orthopedics arrived at 1:30 a.m. The wounds were stitched closed by orthopedics at 2:00 a.m. Reimplantation of the saved digits could not be performed within eight hours from the time of injury as an operating room would not have been available that quickly.

An expert witness in the malpractice case testified that eight hours for reimplantation of digits is

…about the upper limit without trying to break records

The emergency medicine physician was found negligent for not contacting orthopedics sooner. Due to this prolonged period of time, among other negligent acts by orthopedics, the patient and his wife were awarded $525,000.00.

In retrospect, it is easy to see how five-and-a-half hours seems too long when we focus all of our attention on one patient, especially in the courtroom. When that time is broken down, however, we see how easily it can occur. Registration of the patient may prevent ordering studies. There are bottlenecks in radiology due to limited resources. The same patient may require other interventions such as labs, antibiotics, and pain medications. Sicker patients in the Emergency Department may divert our attention and require more of our time. This problem is compounded when consults pressure us to “package” patients before they are consulted, i.e. with all of their labs, studies, and radiographs completed.

In the Emergency Department, it is important to recognize system failures and distractions that will undermine timely interventions and consultations. Perhaps “packaging” every patient before contacting the consulting service is unwise. Finally, whatever the systems failure or distraction, it must be remembered that it is the emergency medicine physician who is ultimately accountable for those delays in time. We are responsible for making it happen.

Dainius A. Drukteinis, M.D., J.D. is an Attending Physician at MetroWest Medical Center in Framingham, Massachusettes. He may be contacted at ddrukteinis@gmail.com