Podcast #252: Mandible Fractures

Author: Sam Killian, M.D.

Educational Pearls

  • The tongue blade test is done for mandible fractures, which make up 40-60% of facial fractures.
  • The test is done by having the patient bite down on a tongue depressor on one side of the mouth. The provider then tries to snap the tongue depressor. This is repeated on the other side of the mouth. The test is positive if the patient complains of pain before the depressor can be broken on either side.  
  • It has been compared to CT and X-ray and has a similar sensitivity and specificity (95% and 65%, respectively).

References: J. Neiner, et al. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofac Trauma Reconstr. 2016

Podcast #242: Clavicle Fracture Review

Author: Nick Hatch, M.D.

Educational Pearls

  • The force required to break a clavicle is significant, so clavicle fracture may be associated with other injury (pneumothorax, vascular injury).
  • Most fractures occur in the middle 1/3 of the clavicle.
  • Traditionally, clavicle fractures have been managed without surgery. However, recent studies have shown that surgery may be beneficial in a larger population than previously thought.

References: http://emedicine.medscape.com/article/398799-overview

Podcast #215: Ankle Pain

Author: Donald Stader, M.D.

Educational Pearls:

  • The most common ankle injury mechanism is an inversion.
  • Most common broken bone in the ankle is the fibula.
  • During exam, it is important to palpate over the fibular head, medial and lateral malleoli, over the 5th metatarsal and over the cuboid bone. If no tenderness in these areas and the patient is walking – they have a  sprain and can be sent home without imaging.
  • In calcaneal fractures, make sure to image the lumbar spine since up to 30% of calcaneal fractures are associated with lumbar spine injury.

References: http://orthosurg.ucsf.edu/oti/patient-care/divisions/sports-medicine/physical-examination-info/ankle-physical-examination/

Podcast #207: Boxer’s Fracture

Author: Sam Killian, M.D.

Educational Pearls:

  • Defined as fracture of neck (distal segment) of 5th metacarpal.
  • Intrinsic muscles of hand pull segment to palmar aspect of hand.
  • 30 degrees of angulation is allowed. Any more increases risk of chronic pain, grip strength and grasping deficits, and rotational deformities.
  • Reduce fracture if more than 30 degrees of angulation or if rotation is present.
  • Splint fracture in “ulnar gutter” with goal being flexion at MCP and extension at DIP and PIP.

References: http://www.emedicinehealth.com/boxers_fracture/article_em.htm

Podcast #200: Non-traumatic Back Pain

Author: Don Stader M.D.

Educational Pearls:

  • Non-traumatic back pain is a very common complaint in the Emergency Department.
  • Conditions that can manifest with back pain include: ruptured abdominal aortic aneurysm, retroperitoneal bleeding, cauda equina syndrome, epidural abscess or cancer.
  • Patients with cauda equina syndrome or epidural abscess prefer to sit forward, while people with disc issues tend to sit upright.

References: https://emergencymedicinecases.com/episode-26-low-back-pain-emergencies/


Podcast #191: Blunt Cervical Trauma

Author: Chris Holmes M.D.

Educational Pearls:

  • Mechanism of injury involves hyperextension/hyperflexion
  • Pathophysiology: inside of the arteries in the neck becomes disrupted, similar to a dissection. This is thrombogenic and leads to cerebral infarction
  • Neurologic deficit is common.
  • Other risk factors include facial fracture and cervical-spine fracture.
  • Treat with anticoagulation – aspirin or other antiplatelet agents are appropriate.
  • Increase clinical suspicion when patient presents with neurological deficit and has a negative CT.

References: https://www.east.org/education/practice-management-guidelines/blunt-cerebrovascular-injury


Podcast #176: Football Injuries

0c0fc049-f8e1-41cb-a236-47f02a359e71Run Time:  4 minutes

Author: Michael Hunt M.D.

Educational Pearls:

  • Stinger – a stretch of cervical nerves from a lateral blow to the head and causes immediate pain and numbness in the arm. There is no specific treatment, and symptoms last seconds to minutes or as long as a few days. A small percentage of stingers result in significant neurologic damage.
  • Hip pointer – a contusion of the pelvis most commonly at the iliac crest.
  • Sports hernia – a soft tissue injury (muscle, ligament, tendon) that is torn or damaged in the groin or pelvic area. Some more serious tears may require surgery.
  • Turf toe – hyperextension of the great toe that puts stress on MTP joint and causes a strain or sprain of the tendons. Categorized into grades 1, 2, & 3 based on severity from least serious to most serious.

Link to Podcast: http://medicalminute.madewithopinion.com/football-injuries/

References: http://www.stopsportsinjuries.org/STOP/Prevent_Injuries/Football_Skating_Injury_Prevention.aspx

Podcast #174: Cervical Spine

8a7dc42a-f8b2-43c0-b61b-0beac1397e14Run Time:  5 minutes

Author: Dylan Luyten M.D.

Educational Pearls:

  • Cervical spine immobilization is a big change in the EMS protocol over several years.
  • Cervical collars were developed for rehabilitation after neck or spine surgery, but became a tool for prehospital treatment of undifferentiated trauma patients that may or may not have injured the neck.
  • There is no real evidence that the cervical collar prevents secondary spinal cord injury.
  • The problem is that these patients may not even exist. The forces to injure the cervical spine – transect the bones or tear ligaments – are so great the it is unlikely that the cervical spine was not also injured during the initial trauma.
  • Deterioration of a patient with a possible cervical spine injury are likely due to increasing edema and ischemia in the spinal cord.
  • The cervical collar does not diminish the force on the neck even with restriction of movement.

Link to Podcast: http://medicalminute.madewithopinion.com/the-cervical-spine/

References: http://www.jems.com/articles/print/volume-40/issue-2/patient-care/why-ems-should-limit-use-rigid-cervical.html

Podcast #149: TMJ Dislocation

e3f99d2b616c9e4c6b8920b6f2ff10_big_galleryRun Time: 3 minutes

Author: Jared Scott M.D.

Educational Pearls:

  • TMJ dislocations are generally a rare occurrence. Connective tissue disorders such as Ehlers-Danlos syndrome and Marfan syndrome increase the likelihood of dislocation.
  • TMJ dislocations can occur after benign activities such as eating, yawning, vomiting, dental treatment, and laughing, but also occur after trauma.
  • Three common techniques for reduction include: 1) Hooking both thumbs over the patient’s canines, placing a Bite Block in the mouth, and pulling down on the jaw 2) Performing the same technique as #1, but from behind the patient 3) Placing a 5-10g syringe in the back of the patient’s mouth near the molars and instructing the patient to attempt to roll the syringe around.
  • Once the jaw is reduced, patient’s with brackets will have their jaw wired shut, which is the same principle as a shoulder dislocation getting a sling to promote healing.
  • Be aware of where the wire cutters are in the emergency room in case of a patient with a wired jaw needs an emergent airway.

Link to Podcast: http://medicalminute.madewithopinion.com/tmj-dislocation/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668726/


Podcast #148: Knee Dislocation

4ecce1c5-678a-4ad3-be1e-06469ce3fd90Run Time:  4 minutes

Author: Samuel Killian M.D.

Educational Pearls:

  • A true knee dislocation and a patellar dislocation are slightly different conditions. A true knee dislocation is the translation of the femur and the tibia – described as anterior/posterior, posterior/anterior, medial/lateral.
  • Knee dislocations occur after a high force blow to the leg.
  • 50% of the time the knee can be self-reduced or naturally reduced prior to presentation to the ED. Otherwise the knee dislocation is totally obvious.
  • The big concern with a knee dislocation is vascular or nerve injury.
  • Popliteal artery injury occurs approximately 50% of the time. Normally this is evaluated by feeling for pulses, assessing discoloration, but 10% of cases can have normal pulses with serious injury.
  • Patients with popliteal artery injury may need emergent revascularization surgery if there are hard signs of vascular injury.
  • If a patient has no hard signs of vascular injury then ABI (ankle-brachial index) is used to assess the likelihood of injury – ABI of >.9 then there is 95% sensitivity for no significant arterial injury, ABI of <.9 then it is highly likely that there is significant arterial injury.
  • 30% of knee dislocations have peroneal nerve injury, which presents as numbness in 1st web space or trouble with dorsal flexion, however this may be hard to assess due to the patient’s pain.

Link to Podcast: http://medicalminute.madewithopinion.com/knee-dislocation/

References: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC535529/