radER Case 13.3 (#20)

 

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Case 20 Questions

 

1. Which is true for metacarpal fractures?

 

2. Which is true of carpal fractures?

 

3. The most likely complication of the above injury includes…

 

Answers

1. Correct Answer D. ≤ 10° angulation is tolerated in 2nd and 3rd metacarpal shaft fractures. ≤ 20° angulation as tolerated and third and fourth metacarpal shaft fractures. The 10, 20, 30, 40 rule is used for angulation of metacarpal neck fractures with 10° angulation tolerated in second metacarpal neck fracture, 20° angulation and third metacarpal neck fracture, 30° angulation in fourth metacarpal neck fracture, and 40° angulation in the fifth metacarpal neck fracture. Closed reduction of metacarpal shaft fractures is performed by longitudinal traction with dorsal pressure applied to the fracture site.  The 90-90 closed reduction method is used for metacarpal neck fractures. Metacarpal shaft fractures of the most common fractures of the hand accounting for up to 50% of all hand fractures.  Metacarpal base and neck fractures individually account for up to 30% of fractures involving the hand.

2. Correct Answer C. Up to 30% of scaphoid fractures develop avascular necrosis involving the proximal pole. First row fractures or more, and then second row fractures amongst the carpal group.  Scaphoid fracture is the most common amongst the carpal group at up to 70% of fractures.  The triquetral bone is the second most common fracture at up to 14%.  Isolated fractures of the remaining carpal bones accompany 0.2% to 5% individually. Avascular necrosis becomes more common with more proximal fractures of the scaphoid bone rather than distal.

3. Correct Answer B. Ulnar nerve compression. Fracture of the body or hook of Hamate can cause compression of the ulnar nerve as well as the ulnar artery.  Fracture of the capitate can cause compression of the deep motor branch of the ulnar nerve.  A Smith fracture is known to cause median nerve compression mimicking carpal tunnel syndrome.  Radial nerve compression is most likely due to mid humeral shaft fracture, not carpal bone fractures.

radER Case 13.2 (#14)

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Case

25 YOM presents to the ED complaining of sudden onset of right foot pain while playing football earlier today. He states that he was bearing all of his weight on his right foot at the time of the onset of pain. He states that his pain is significantly worsened with bearing weight and ambulation. He denies numbness and tingling. He denies any previous right lower extremity injuries. A right foot x-ray was obtained.

1. What abnormality should be identified in these radiographs?

2. What is the most common secondary/associated fracture involving the above abnormality?

3. Which statement is true of the proper treatment of the above injury?

Case 14 Answers

1. Correct Answer C. Lisfranc Fracture. Separation of the bases of the 1st and 2nd metatarsals should be evident in this film. It also appears as though there may be an avulsion fracture of the base of the 2nd metatarsal associated with the dislocation injury. No evidence of Jones or Pseudo-Jones fracture is noted in these views. No accessory bone is noted near the base of the 5th metatarsal to suggest Os peroneum. Os peroneum is very common seen in nearly 26% of foot x-rays and should not be mistaken for apophysis or avulsion fracture of the 5th metatarsal.

2. Correct Answer A. Base of 2nd Metatarsal Fracture is the most common fracture associated with a Lisfranc injury/dislocation.  Calcaneal fractures are not directly associated with Lisfranc dislocation fractures however should be suspected in MVC trauma patients that sustain Lisfranc injury. Cuboid fractures are seen as a result of Lisfranc dislocation however not as commonly as 2nd metatarsal fractures. Avulsion fractures of the 5th metatarsal are not commonly associated with Lisfranc dislocation.

3. Correct Answer B. ED Orthopedic consultation and evaluation. Lisfranc dislocation injuries all need to be evaluated immediately by an orthopedic surgeon. If unstable, surgery is the only corrective measure. The patient is to be NWB on the affected lower extremity. They should be placed in a short leg splint to stabilize/immobilize the foot and ankle.

Discussion:

Mechanism of Injury

  • Mechanism involves severe plantar flexion of the foot
  • May occur from sports-related injuries
  • Motor vehicle accidents
  • Falling from a height, down stairs or off a curb

Lisfranc ligament diagonally connects the 1st (medial) cuneiform with the base of the 2nd metatarsal. If it remains intact, either an avulsion of the lateral border of the 1st cuneiform or an avulsion of the base or medial border of the 2nd metatarsal occurs. If it tears, these fractures may not occur

Have a high index of suspicion as 20% of cases are undiagnosed due to other sustained trauma

Clinical findings

  • Pain at tarsal-metatarsal joints
  • Ecchymosis
  • Instability

Two basic types

A. Homolateral

  • All of the metatarsals are dislocated to the same side
  • More common than divergent
  • Usually involves the 2nd through 5th dislocated laterally
  • May involve all 5 metatarsals

B. Divergent

  • Usually more severe than homolateral
  • May be associated with a fracture of the 1st cuneiform
  • Usually involves medial displacement of the 1st metatarsal and lateral displacement of 2nd-5th metatarsals
  •  Occasionally may involve only medial displacement of only the 1st metatarsal

Fractures commonly associated with Lisfranc dislocations

  • Base of 2nd metatarsal (most common)
  • Cuboid
  • Fractures of shafts of metatarsals
  • Dislocations of the 1st (medial) and 2nd (middle) and cuneonavicular joints
  • Fractures of the tarsal navicular

Imaging

  • Conventional radiographs are usually sufficient to demonstrate the injury.

Normal alignment of the cuneiforms and the bases of the metatarsals

  • Lateral border of 1st metatarsal is aligned with lateral border of 1st (medial) cuneiform on AP view
  • Medial border of 2nd metatarsal is aligned with medial border of 2nd (intermediate or middle) cuneiform on AP view
  • Medial and lateral borders of the 3rd (lateral) cuneiform should align with medial and lateral borders of 3rd metatarsal on oblique view
  • Medial border of 4th metatarsal aligned with medial border of cuboid on oblique – Lateral margin of the 5th metatarsal may project lateral to cuboid by as many as 3mm on oblique
  • On lateral, a line drawn along long axis of talus should intersect long axis of 5th metatarsal

radER Case 13.1

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CXR PA s/p NGT

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Case 1 Questions

54 YOM presents to emergency department complaining of midsternal chest pain that he states has been coming and going for the past few years.  He states it has worsened over the past week becoming more constant.  He denies exertional component to his chest pain.  He denies any shortness of breath or difficulty breathing.  He does state that he intermittently feels nauseated but does not have any episodes of emesis.  He denies any fevers, chills, and productive cough.  He states that he has a history of hypertension, diabetes, and coronary artery disease with CABG x3.

The patient’s physical examination is unremarkable.

1. What significant abnormality is noted on the PA view of his patient’s chest film?
A. Acute Infiltrate
B. Increased Pulmonary Vascular Congestion
C. Esophageal dilatation
D. Westermark Sign

2. What is the most preferred initial screening/diagnostic test if the above condition is suspected?
A. Barium Swallow
B. CTA Thorax
C. D-Dimer
D. Echocardiogram

3. What is the preferred initial pharmacotherapy?
A. Heparin bolus with subsequent heparin ggt
B. Calcium Channel Blockers or Nitrates
C. Cetriaxone and doxycycline
D. Fondaparinux with warfarin overlap

Case 1 Answers

1. Correct Answer C. Esophageal dilatation with air-fluid level is the most notable abnormality on the PA view of his chest x-ray. This is often seen in an advanced achalasia as the lower esophageal sphincter as constricted and not allowed any liquid or solids to pass causing significant dilatation of the esophagus. No acute infiltrate is noted in the chest x-ray to suggest pneumonia.  No increased pulmonary vascular congestion is appreciated. Pulmonary embolism should be considered however no shortness of breath or history of DVT/PE exists.  No Westermark Sign is noted on his chest x-ray.

2.  Correct Answer A. Barium Swallow is the preferred initial screening test if achalasia is suspected.  Extensive esophageal dilatation is typically only noted 1 chest x-ray in advanced cases. A CTA thorax is the preferred modality for diagnosis of acute pulmonary embolus.  A d-dimer should only be used in the low risk patient’s suspected of having a pulmonary embolus with a Well’s score of less than 2. An echocardiogram is also a good screening test for both acute pulmonary embolism with right heart strain as well as for acute heart failure however it serves no role in the diagnosis of achalasia.

 3.  Correct Answer B. Calcium Channel Blockers or Nitrates are the preferred initial pharmacotherapy for smooth muscle relaxation in patients with achalasia.  Ceftriaxone and doxycycline are preferred for patient’s being admitted with acute community acquired pneumonia. Heparin bolus with subsequent drip is preferred in patients with acute pulmonary embolus that may undergo PCI. Fondaparinux with Coumadin overlap is preferred for stable patient’s with acute pulmonary embolus.

Answer radER Vol. 1.6

radER Winners:

Allison Loynd

Answer to Case 1.6

A 49-year old man fell off a ladder 4 days ago and continues to have pain in his right wrist. He denies pain in other parts of his body.  On examination, there is tenderness and swelling at the dorsal medial aspect of his wrist.  The patient receives a dose of oral analgesic medication.  The following radiograhs are obtained.

Questions

1.  What is the radiographic diagnosis?

2.  What is the most appropriate ED treatment and follow up?

Answers

1.  Acute triquetral dorsal chip fracture.
2.  Volar splint and follow up with an orthopedic or hand surgeon within 7-10 days

The above radiographs show a small dorsal chip on the lateral radiograph.  This is pathognomonic for a triquetral fracture.  The triquetrum is the second most commonly fractured carpal bone.  The mechanism of injury can either be forced hyperextension, hyperflexion or a direct blow.  Patients typically have pain and swelling on the dorsal medial aspect of the wrist.  Tenderness is often palpated just distal to the distal ulna and ulna styloid.  The triquetrum has a very rich vascular supply and non-union is usually not an issue.  All patients should be splinted and given orthopedic or hand surgeon follow-up.

Wrist radiographs can be difficult to interpret and missed injuries are common.  Radiograph interpretation is aided by knowing which injuries are common, which can be easily missed, and the findings on physical examination.  In the wrist, distal radius fractures are by far most common and, although usually obvious, the radiographic findings are occasionally subtle or the radiographs are normal (an occult fracture).

Among carpal injuries, scaphoid fractures account for 60%.  The radiographs may have subtle findings or be normal.  The second most commonly fractured carpal is the triquetrum – a dorsal chip fracture that is seen on the lateral view.  (The triquetrum is the most dorsally projecting carpal bone on the lateral view.)  When a patient with a wrist injury presents with pain and swelling on the dorsum of the wrist, a dorsal chip triquetrum fracture should be suspected and the lateral view examined for this injury.  In this patient, there is also soft tissue swelling over the dorsal surface of the wrist on the lateral view.  Dorsal chip fractures of the triquetrum account for 20% of carpal injuries.

Most of the remaining 20% of carpal injuries are “perilunate injuries,” a spectrum of ligmentous injuries, subluxations, dislocations and fractures in proximity to the lunate.  Injuries of other carpals are uncommon, but can also be difficult to detect radiographically.  Therefore, any patient with significant wrist pain following an injury should be splinted and referred to an orthopedist or hand surgeon for further evaluation.  This may entail repeat radiographs, a bone scan (no longer used), MRI or possibly MDCT.

trquetrum

References:

Schwartz DT: Emergency Radiology: Case Studies, McGraw-Hill, 2008, pp.249-256, 257-266.

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.

radER vol. 1.6

Case 1.6

A 49-year old man fell off a ladder 4 days ago and continues to have pain in his right wrist. He denies pain in other parts of his body.  On examination, there is tenderness and swelling at the dorsal medial aspect of his wrist.  The patient receives a dose of oral analgesic medication.  The following radiograhs are obtained.

Questions

1.  What is the radiographic diagnosis?

2.  What is the most appropriate ED treatment and follow up?

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.

radER 3.2 Answer

rader new

Winners

David Mishkin

Marjan Siadat

Claire Jensen

Richard Gordon

Ayse Avcioglu

Case

A 23-year-old man presents to the ED complaining of left thumb pain after he collided with another player during a rugby match. There is swelling and tenderness at the base of the thumb.  You think the patient may have sustained a fracture of his proximal thumb so you order radiographs.  One of the radiographs is seen below:

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Questions

1. What is the eponym for this fracture?

2. What is the ED management for this fracture?

3. Is the prognosis better or worse than the fracture seen in radER 3.1

Answers

1. Rolando Fracture – This is a  Y-shaped fracture of the base of the thumb metacarpal.  It can be considered an intraarticular, comminuted Bennett fracture.

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2. ED Management requires a thumb spica splint and referral to a Hand specialist

3. The prognosis of a Rolando fracture is worse than a Bennett fracture, and operative fixation is usually necessary.

radER is a weekly contest consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

radER 3.2

rader new

Case

A 23-year-old man presents to the ED complaining of left thumb pain after he collided with another player during a rugby match. There is swelling and tenderness at the base of the thumb.  You think the patient may have sustained a fracture of his proximal thumb so you order radiographs.  One of the radiographs is seen below:

thumb 2

Questions

1. What is the eponym for this fracture?

2. What is the ED management for this fracture?

3. Is the prognosis better or worse than the fracture seen in radER 3.1

Please click on the “comments” link or post your answer in the “reply box”. 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 consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.