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The Unintended Off-road Experience
ANSWER
A moderate amount of soft-tissue swelling is evident. There is also a fracture of the distal radius and an avulsion fracture of the triquetrum. The latter is the second most commonly fractured carpal bone after the scaphoid. Triquetral fractures usually result from a hyperflexion injury.
The patient’s wrist was immobilized in a splint, and referral to a hand surgeon was coordinated.
ANSWER
A moderate amount of soft-tissue swelling is evident. There is also a fracture of the distal radius and an avulsion fracture of the triquetrum. The latter is the second most commonly fractured carpal bone after the scaphoid. Triquetral fractures usually result from a hyperflexion injury.
The patient’s wrist was immobilized in a splint, and referral to a hand surgeon was coordinated.
ANSWER
A moderate amount of soft-tissue swelling is evident. There is also a fracture of the distal radius and an avulsion fracture of the triquetrum. The latter is the second most commonly fractured carpal bone after the scaphoid. Triquetral fractures usually result from a hyperflexion injury.
The patient’s wrist was immobilized in a splint, and referral to a hand surgeon was coordinated.
A 70-year-old woman is brought to the emergency department by EMS after being involved in a motor vehicle collision. She was a restrained driver in a vehicle that was hit by a tractor-trailer, causing her vehicle to go off the road and hit the guardrail. She does not recall if the airbag deployed, and she believes she momentarily lost consciousness. She is complaining of pain in the head and the right wrist.
Her medical history is significant for mild (controlled) hypertension. Primary survey reveals an elderly female who is awake, alert, and oriented and in mild distress. Her vital signs are stable.
The patient has a small laceration on her face. Her right wrist is moderately swollen, and she has decreased range of motion. There is also moderate tenderness to palpation. Pulses are good, as is capillary refill time in the fingernail bed.
Radiograph of the right wrist is obtained (oblique view shown). What is your impression?
There’s No Patellin’ What Happened
ANSWER
The radiograph demonstrates an abnormal-appearing patella; there is a longitudinal lucency along the lateral portion. There is some mild soft-tissue swelling but no evidence of a definite joint effusion. The lucency could represent a fracture, especially in the setting of trauma. The other possibility is that the patient has a bipartite patella. This is a rare congenital condition in which the patella does not completely fuse; it remains two separate bones. CT of the knee for further evaluation, as well as orthopedic consultation, were ordered.
ANSWER
The radiograph demonstrates an abnormal-appearing patella; there is a longitudinal lucency along the lateral portion. There is some mild soft-tissue swelling but no evidence of a definite joint effusion. The lucency could represent a fracture, especially in the setting of trauma. The other possibility is that the patient has a bipartite patella. This is a rare congenital condition in which the patella does not completely fuse; it remains two separate bones. CT of the knee for further evaluation, as well as orthopedic consultation, were ordered.
ANSWER
The radiograph demonstrates an abnormal-appearing patella; there is a longitudinal lucency along the lateral portion. There is some mild soft-tissue swelling but no evidence of a definite joint effusion. The lucency could represent a fracture, especially in the setting of trauma. The other possibility is that the patient has a bipartite patella. This is a rare congenital condition in which the patella does not completely fuse; it remains two separate bones. CT of the knee for further evaluation, as well as orthopedic consultation, were ordered.
A 30-year-old man is transported by ambulance to your emergency department from the scene of a motor vehicle collision. He was a restrained driver who lost control of his vehicle and hit the back of a tractor-trailer. His airbag deployed, and he thinks he had a brief loss of consciousness. He complains of pain in his neck, right-side chest wall, and right knee.
He denies any significant medical history and takes no medications regularly. He reports smoking a half-pack of cigarettes per day and consuming alcohol socially; he denies drinking this evening.
Primary survey shows a male in no obvious distress who is currently awake, alert, and oriented. His Glasgow Coma Scale score is 15. Primary exam is stable except for some neck pain and right-side rib pain.
During secondary survey, examination of his right knee shows a superficial laceration with controlled bleeding. No significant swelling is present. The patient does have decreased range of motion secondary to a moderate amount of pain. Distal pulses are present, and there is no neurovascular compromise.
You obtain a portable radiograph of the knee (shown). What is your impression?
Taking a Stab in the Dark
ANSWER
The radiograph shows an obvious metallic foreign body that appears to be lodged within the first and second lumbar disc space. This is likely the tip of the knife, which presumably broke off when the patient was stabbed.
The patient was promptly transferred to a trauma center with neurosurgery coverage. Subsequent CT showed that the blade had penetrated the spinal canal, but remarkably, the patient remained neurologically intact. He underwent successful removal without any neurologic compromise.
This case highlights several points for clinicians: First, provider-to-provider sign-out of patients should be complete and detailed. Second, obtaining a thorough history is essential. And third, you should maintain a low threshold for obtaining radiographs of wounds, to rule out a foreign body.
ANSWER
The radiograph shows an obvious metallic foreign body that appears to be lodged within the first and second lumbar disc space. This is likely the tip of the knife, which presumably broke off when the patient was stabbed.
The patient was promptly transferred to a trauma center with neurosurgery coverage. Subsequent CT showed that the blade had penetrated the spinal canal, but remarkably, the patient remained neurologically intact. He underwent successful removal without any neurologic compromise.
This case highlights several points for clinicians: First, provider-to-provider sign-out of patients should be complete and detailed. Second, obtaining a thorough history is essential. And third, you should maintain a low threshold for obtaining radiographs of wounds, to rule out a foreign body.
ANSWER
The radiograph shows an obvious metallic foreign body that appears to be lodged within the first and second lumbar disc space. This is likely the tip of the knife, which presumably broke off when the patient was stabbed.
The patient was promptly transferred to a trauma center with neurosurgery coverage. Subsequent CT showed that the blade had penetrated the spinal canal, but remarkably, the patient remained neurologically intact. He underwent successful removal without any neurologic compromise.
This case highlights several points for clinicians: First, provider-to-provider sign-out of patients should be complete and detailed. Second, obtaining a thorough history is essential. And third, you should maintain a low threshold for obtaining radiographs of wounds, to rule out a foreign body.
As you arrive for your shift in the emergency department, the outgoing provider asks if you would mind checking a laceration that his student is stapling. “The discharge paperwork is all done,” he says, as he waves goodbye and walks out the door.
You find that the student has just about completed his task: sterilely stapling a 2.5-cm laceration on the left lumbar area of a man in his early 40s.
You ask the student for the basic history, and he informs you that the patient was drinking with friends and “accidentally got cut” when they started roughhousing. You turn your attention to the patient, who appears intoxicated but in no obvious distress; he confirms the story as presented.
A quick review of the chart shows no significant medial history, stable vital signs, and up-to-date tetanus status. The patient can move all extremities well and appears neurovascularly intact. But some instinct prompts you to probe further.
On additional questioning, the patient reveals that he was accidentally stabbed. When you inquire about the object he was stabbed with, he describes it as a knife, “pretty long, sort of like a dagger.”
With this information, you decide to order some laboratory studies and abdominal radiographs (lateral view shown). What is your impression?
Thrown Off Track
ANSWER
The radiograph shows rib fractures on the left side (arrows); on the same side, there is a moderate-sized pleural effusion—presumably a hemothorax from the trauma.
A closer look at the mid-thoracic spine reveals some irregularity and possible deformity—note the slight offset. This finding is strongly suspicious for a fracture.
A subsequent CT revealed a thoracic burst fracture with retropulsion into the spinal canal.
ANSWER
The radiograph shows rib fractures on the left side (arrows); on the same side, there is a moderate-sized pleural effusion—presumably a hemothorax from the trauma.
A closer look at the mid-thoracic spine reveals some irregularity and possible deformity—note the slight offset. This finding is strongly suspicious for a fracture.
A subsequent CT revealed a thoracic burst fracture with retropulsion into the spinal canal.
ANSWER
The radiograph shows rib fractures on the left side (arrows); on the same side, there is a moderate-sized pleural effusion—presumably a hemothorax from the trauma.
A closer look at the mid-thoracic spine reveals some irregularity and possible deformity—note the slight offset. This finding is strongly suspicious for a fracture.
A subsequent CT revealed a thoracic burst fracture with retropulsion into the spinal canal.
A 20-year-old man is riding a four-wheel all-terrain vehicle at a high rate of speed when he loses control and is thrown off. He is not wearin
As you begin your primary survey, you note a young male who is anxious but awake and able to converse. He is receiving 100% oxygen via a non-rebreather mask. His heart rate is 130 beats/min and his blood pressure, 80/40 mm Hg. Breath sounds are somewhat decreased on the left side. The patient can move both arms, and his strength is normal. However, he is insensate from his mid-chest down and is unable to move his legs at all.
Portable radiographs are obtained, including a chest radiograph (shown). What is your impression?
All-Terrain, No Control
ANSWER
The image shows a large, convex hyperdensity within the left parietal region. This is a textbook image of an acute epidural hematoma. There is considerable mass effect and evidence of left-to-right shift. Windowing shows an underlying fracture, which is typically associated with these types of hemorrhages.
There is also evidence of a right-side concave hyperdensity, consistent with an acute subdural hematoma. Typically, this is referred to as a contrecoup injury.
The patient was transported to the operating room for an emergent left craniotomy for epidural evacuation; he recovered uneventfully.
ANSWER
The image shows a large, convex hyperdensity within the left parietal region. This is a textbook image of an acute epidural hematoma. There is considerable mass effect and evidence of left-to-right shift. Windowing shows an underlying fracture, which is typically associated with these types of hemorrhages.
There is also evidence of a right-side concave hyperdensity, consistent with an acute subdural hematoma. Typically, this is referred to as a contrecoup injury.
The patient was transported to the operating room for an emergent left craniotomy for epidural evacuation; he recovered uneventfully.
ANSWER
The image shows a large, convex hyperdensity within the left parietal region. This is a textbook image of an acute epidural hematoma. There is considerable mass effect and evidence of left-to-right shift. Windowing shows an underlying fracture, which is typically associated with these types of hemorrhages.
There is also evidence of a right-side concave hyperdensity, consistent with an acute subdural hematoma. Typically, this is referred to as a contrecoup injury.
The patient was transported to the operating room for an emergent left craniotomy for epidural evacuation; he recovered uneventfully.
A 40-year-old man is brought to the emergency department (ED) with a suspected intracranial hemorrhage after being thrown off an all-terrain vehicle. He was reportedly riding the vehicle without a helmet when he somehow lost control; the accident itself was unwitnessed.
En route to the ED, he was reportedly confused but hemodynamically stable, with a Glasgow Coma Scale score of 13-14. He lost consciousness while in the CT scanner, requiring emergent intubation for airway protection.
When you arrive to assess him, you note an intubated male with stable vital signs. The pupils display slight anisocoria but equally react. The patient withdraws in all four extremities secondary to pain, with slight posturing.
Noncontrast CT of the head is obtained, a static image from which is shown. What is your impression?
From Local Bar to Police Car
ANSWER
The radiograph demonstrates no acute injury to the wrist. There is, however, a subtle nondisplaced fracture of the distal fifth metacarpal joint. The patient was given a wrist splint for symptomatic relief, and orthopedic follow-up was coordinated.
ANSWER
The radiograph demonstrates no acute injury to the wrist. There is, however, a subtle nondisplaced fracture of the distal fifth metacarpal joint. The patient was given a wrist splint for symptomatic relief, and orthopedic follow-up was coordinated.
ANSWER
The radiograph demonstrates no acute injury to the wrist. There is, however, a subtle nondisplaced fracture of the distal fifth metacarpal joint. The patient was given a wrist splint for symptomatic relief, and orthopedic follow-up was coordinated.
A 31-year-old man is brought to your facility by local law enforcement for evaluation of left wrist pain following an altercation. The patient was reportedly at a local bar; as he was leaving, he started arguing with some other patrons. A fight ensued.
The patient believes he was struck by something on his left wrist. He denies any other injuries or complaints. His medical history is unremarkable, and vital signs are stable.
Physical examination of his left wrist shows no obvious deformity. There is some mild swelling over the dorsal aspect of his wrist. Range of motion is painful and limited. Good capillary refill is noted in the fingers, and sensation is intact. Good pulses are present.
Radiograph of the left wrist is obtained. What is your impression?
His Old Pain Is Back
ANSWER
The radiograph demonstrates a fracture within the femoral neck. These types of fractures, which are slightly angulated and located at the base of the neck, are typically referred to as basicervical femur fractures.
Prompt orthopedic surgery consultation was obtained, and the patient underwent an open reduction and internal fixation of his fracture.
ANSWER
The radiograph demonstrates a fracture within the femoral neck. These types of fractures, which are slightly angulated and located at the base of the neck, are typically referred to as basicervical femur fractures.
Prompt orthopedic surgery consultation was obtained, and the patient underwent an open reduction and internal fixation of his fracture.
ANSWER
The radiograph demonstrates a fracture within the femoral neck. These types of fractures, which are slightly angulated and located at the base of the neck, are typically referred to as basicervical femur fractures.
Prompt orthopedic surgery consultation was obtained, and the patient underwent an open reduction and internal fixation of his fracture.
You are called in for a neurosurgical consult of a 60-year-old man who underwent a lumbar decompression approximately 18 months ago. For the past several weeks, he has been experiencing worsening back pain that radiates down his left leg; at times, he has to use his cane and walker. The patient denies any acute injury or trauma preceding the pain; however, last night he slipped and fell in his bedroom, which made it much worse.
Medical history is significant for hypertension and hyperlipidemia. The patient responded well to his previous back surgery. The emergency department clinician is concerned that his symptoms may be caused by a new lumbar stenosis at an adjacent level.
On exam, you note a mildly obese male who appears uncomfortable but is in no obvious distress. His vital signs are stable. He has some tenderness within his left hip. Distally, his strength is good, and there is no evidence of neurovascular compromise. Internal and external rotation causes some discomfort.
A portable pelvic radiograph is obtained (shown). What is your impression?
The Deer Stand Strikes Back
ANSWER
The radiograph demonstrates a compression fracture of T12 with moderate loss of height approaching 50% anteriorly. In addition, there is a vertically oriented fracture within the middle of the vertebral body, causing the back portion to be posteriorly displaced.
This type of burst fracture is potentially unstable and should be treated as such. The patient was placed on strict spine precautions and transferred to a facility where trauma and neurosurgical services were available.
ANSWER
The radiograph demonstrates a compression fracture of T12 with moderate loss of height approaching 50% anteriorly. In addition, there is a vertically oriented fracture within the middle of the vertebral body, causing the back portion to be posteriorly displaced.
This type of burst fracture is potentially unstable and should be treated as such. The patient was placed on strict spine precautions and transferred to a facility where trauma and neurosurgical services were available.
ANSWER
The radiograph demonstrates a compression fracture of T12 with moderate loss of height approaching 50% anteriorly. In addition, there is a vertically oriented fracture within the middle of the vertebral body, causing the back portion to be posteriorly displaced.
This type of burst fracture is potentially unstable and should be treated as such. The patient was placed on strict spine precautions and transferred to a facility where trauma and neurosurgical services were available.
A 45-year-old man presents to your facility for evaluation of ongoing back pain. He reports that he fell out of a deer stand from an approximate height of 15 to 20 ft. He landed on his back but was able to get up, walk a short distance to his car, and drive home. Persistent pain is what brings him to the emergency department to seek treatment.
He denies any weakness or numbness in his lower extremities. There are no bowel or bladder issues. His medical history is unremarkable.
On physical examination, you note a moderately uncomfortable male whose vital signs are normal. He is able to move all four extremities well, and his strength is intact throughout. He does have moderate tenderness within the thoracolumbar region, with no step-off appreciated. The paraspinous muscles are tender as well.
You order lumbosacral radiographs (lateral view shown). What is your impression?
Brace for Impact
ANSWER
The radiograph shows an oblique fracture through the radial styloid process. The patient was placed in a splint and referred to outpatient orthopedics for follow-up.
ANSWER
The radiograph shows an oblique fracture through the radial styloid process. The patient was placed in a splint and referred to outpatient orthopedics for follow-up.
ANSWER
The radiograph shows an oblique fracture through the radial styloid process. The patient was placed in a splint and referred to outpatient orthopedics for follow-up.
A 35-year-old woman arrives at the emergency department following a motor vehicle accident. She was a restrained driver who was crossing an intersection when another vehicle pulled out in front of her. She recalls gripping the steering wheel in anticipation of impact. No air bags deployed. She complains of wrist pain, but denies any other ailment.
Medical history is unremarkable. Vital signs are normal. Physical examination of the patient’s left wrist shows no obvious deformity. There is mild soft-tissue swelling, decreased range of motion, and moderate point tenderness along the radial aspect of the wrist. The nailbeds have good capillary refill. Strong pulses are present, as well.
Triage has already obtained a radiograph of the left wrist (shown). What is your impression?
