Clinical Video: abnormal hand twitching

Case Presentation

A 43-year-old female presented with altered mental status (GCS of 10/15) and abnormal twitching of hand. Reported to have a long-standing history of constipation and had been on laxatives. POC electrolytes showed Sodium: 110 mmol/L, Potassium: 3.5 mmol/L and Calcium: 0.71 mmol/L. The case managed as symptomatic euvolemic hyponatremia, hypocalcemia, and SIADHS.

Symptoms of hypocalcemia

Numbness and/or tingling of the hands, feet, or lips, muscle cramps, muscle spasms, seizures, facial twitching, muscle weakness, lightheadedness, and bradycardia.

Symptoms of hyponatremia

Nausea and vomiting, headache, confusion, loss of energy, drowsiness and fatigue, restlessness and irritability. muscle weakness, spasms or cramps, seizures, coma.

At the presentation time of the patient, you may not know these muscle spasms are because of hypocalcemia and hyponatremia’s similar symptoms. So, laboratory tests can clarify the diagnosis. However, in this case, both (Ca and Na) are low. So, you treat both. 

In addition

There are two findings related to hypocalcemia which worth to mention. Chvostek’s sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve. Trousseau’s sign is carpopedal spasm caused by inflating the blood pressure cuff to a level above systolic pressure for 3 minutes. This video shows both findings.

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Clinical Image: rhabdomyosarcoma?

862.1 - rhabdomyosarcoma 1

A 35-year-old male with a seven-month history of right supraclavicular mass. No compressive symptoms. Clinical and Xray interpretation was soft tissue rhabdomyosarcoma.

862.2 - rhabdomyosarcoma 2
862.3 - rhabdomyosarcoma 3

Rhabdomyosarcoma is one of the aggressive and malignant cancers of skeletal (striated) muscle cells. The cases are mostly young, particularly below age 18. It may arise from al body regions. However, head and neck, urinary and reproductive system, extremities are common locations.

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Lover’s Fracture

A 35-year-old construction worker was brought in by the ambulance to the Emergency Department. He was reported to have fallen from scaffolding at the height of approximately 4 meters and landed onto the concrete floor below feet first. He was found conscious by paramedics but in obvious pain, holding his right leg. Upon initial examination in the ED, the patient remains vitally stable but complains of severe, persistent pain in his right ankle and heel. After adequate analgesia, an X-ray of the right ankle and foot revealed signs of a calcaneal "Lover’s" fracture (Figure 1).

Figure 1
Figure 1: Image courtesy of Annelies van der Plas, and J.L. Bloem - http://www.startradiology.com/internships/general-surgery/ankle/x-ankle/

Calcaneal Fractures

Before we begin our discussion on calcaneal fractures, it is important to highlight the major anatomical structures visible on a standard X-ray of the ankle and foot.

Figure 2
calcaneus and foot anatomy

Figure 2 shows a lateral x-ray of the right ankle, demonstrating the calcaneus as the bone – commonly referred to as the heel – that makes up the majority of the hindfoot.

As would be expected, the size and position of the calcaneus predispose the bone to various forms of injury. A calcaneal fracture is most often sustained after a road traffic accident or a fall from significant height onto the feet as was the case with our patient. Due to the mechanism of injury, it is often colloquially dubbed as “Lover’s fracture” or the “Don Juan fracture”(1).

Epidemiology

Among fractures of the hindfoot, calcaneal fractures comprise 50-60% of all tarsal bone fractures (2). These fractures are usually intra-articular (3) and occur more commonly in young men aged between 20 and 40 years. Diseases which decrease bone density, such as osteoporosis, invariably increase the risk for development of the fracture when injury occurs.

Patient evaluation

Patients with calcaneal fractures will often present in severe pain, though they may not always be able to localize the exact source for their pain. Swelling at the ankle or heel along with bruising (ecchymosis) can also be expected. Due to the mechanism of fall, injury usually occurs bilaterally. Most patients are unable to bear any weight onto the affected limb.

The lower extremity or extremities in question should undergo a thorough neurovascular exam, as diminished pulses distal to the injury (dorsalis pedis) could indicate arterial compromise and mandate aggressive investigation with angiography or Doppler scanning. Though the gold standard for diagnosing calcaneal fractures remains a CT scan, a plain film X-ray is usually obtained first which should include an Antero-Posterior (AP), a lateral, and an oblique view.

Bohler’s Angle and Critical Angle of Gissane

Historically, physicians would measure Bohler’s angle and the critical angle of Gissane in cases where a calcaneal fracture was not clearly evident on a plain X-ray. Outlined in Figure 3, a calcaneal fracture would be suspected if Bohler’s angle was below 20 degrees or the critical angle of Gissane was noted to be more than 140 degrees. Bohler’s angle was found to be a lot more diagnostically reliable when compared to the critical angle of Gissane (4). However, both these methods of diagnosis are now considered obsolete and the same research that studied that utility of the angles found that Emergency Physicians were able to accurately identify calcaneal fractures approximately 98% of the time without the measurement of either angle.

Figure 3
853 - bohler angle - calcaneus
854 - Gissane angle- calcaneus

Figure 3- Bohler’s Angle and Critical angle of Gissane

Management

The goal of initial management in the Emergency Department is centered on adequate pain relief, immobilization and wound care (including antibiotics when there are signs of a contaminated wound). [See the link for open fractures and antibiotic choices.]

An important point to note is that the mechanism of injury in calcaneal fractures (namely fall from height) is a form of axial loading. The energy from landing on the ground will often be transmitted up through the body, usually to the spine causing compression fractures of the vertebrae. The patient, however, may not complain about pain in other areas due to the overwhelming and distracting pain in the calcaneus. Therefore, all calcaneal fractures should be managed with a high index of suspicion for associated injuries.

Other potential complications include compartment syndrome, wound infection, malunion and osteomyelitis. All patients diagnosed to have calcaneal fractures should be managed by a multidisciplinary team that includes an Orthopedic Surgeon to ensure definitive management and repair of the fracture.

Take Home Points

  • High energy impact with axial loading, usually from a road traffic accident or a fall from height should raise suspicion of a calcaneal fracture.

  • Perform a thorough evaluation of the site of injury and suspect associated injuries (check the spine and remember to check the other foot for concomitant injury).

  • Maintain adequate analgesia (these fractures hurt!) and involve the Orthopedic Surgeon as soon as the diagnosis is made.

References and Further Reading

  1. Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these names? Radiographics. 2004;24 (4): 1009-27. doi:10.1148/rg.244045015
  2. Davis D, Newton EJ. Calcaneus Fractures. [Updated 2019 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  3. Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. Orthop. Relat. Res. 2019 Feb;477(2):467-471
  4. Jason R. K., Eric A. G., Gail H. B., Curt B. H. & Frank L. Boehler’s angle and the critical angle of gissane are of limited use in diagnosing calcaneus fractures in the ED. American Journal of Emergency Medicine. 24, 423–427 (2006)

A 57-year-old man fell from a height comes with neck pain

by Stacey Chamberlain

A 57-year-old man fell from a height of 12 feet while on a ladder. He did not pass out; he reports that he simply lost his footing. He fell onto a grassy area, hitting his head and complains of neck pain. He did not lose consciousness and denied headache, blurry vision, vomiting, weakness, numbness or tingling in any extremities. He denies other injuries. He was able to get up and ambulate after the fall and came in by private vehicle. He has not had previous spine surgery and does not have known vertebral disease. On exam, he is neurologically intact with a GCS of 15, does not appear intoxicated and has moderate midline cervical spine tenderness.

Should you get imaging to rule out a cervical spine fracture?

C-spine Imaging Rules

Canadian C-spine Rule

NEXUS Criteria for C-spine Imaging

  • Age ≥ 65
  • Extremity paresthesias
  • Dangerous mechanism (fall from ≥ 3ft / 5 stairs, axial load injury, high-speed MVC/rollover/ejection, bicycle collision, motorized recreational vehicle)
  • Focal neurologic deficit present
  • Midline spinal tenderness present
  • Altered level of consciousness present
  • Intoxication present
  • Distracting injury present

Both the Canadian C-spine Rule (CCR) and NEXUS Criteria are widely employed in clinical practice to reduce unnecessary cervical spine imaging in trauma patients with neck pain or obtunded trauma patients. The CCR uses mechanism and age criteria, whereas the NEXUS Criteria incorporates criteria including midline tenderness and additional factors that might limit a practitioner’s exam. The CCR can be difficult for some practitioners to remember all the criteria that qualify as a dangerous mechanism and is limited to ages > 16 and < 65. However, it can be used in intoxicated patients if the patients are alert and cooperative, allowing a full neurologic exam. The NEXUS Criteria are applicable over any age range (> 1 year old), but the sensitivity may be low in patients > 65 years of age. A single comparison study found the CCR to have better sensitivity (99.4% versus 90.7%); however, the study was performed by hospitals involved in the initial CCR validation study.

Case Discussion

By applying either criteria to this case, the patient would require C-spine imaging as by CCR, the patient would meet criteria for dangerous mechanism, and by NEXUS, the patient has midline tenderness to palpation.

A 36-year-old woman slipped on ice. CT or Not CT?

by Stacey Chamberlain

A 36-year-old woman slipped on ice and fell and hit her head. She reports loss of consciousness for a minute after the event, witnessed by a bystander. She denies headache. She denies weakness, numbness or tingling in her extremities and no changes in vision or speech. She has not vomited. She remembers the event except for the transient loss of consciousness. She doesn’t use any blood thinners. On physical exam, she has a GCS of 15, no palpable skull fracture and no signs of a basilar skull fracture.

Should you get a CT head for this patient to rule out a clinically significant brain injury?

Canadian CT Head Rule

High-Risk Criteria (rules out the need for neurosurgical intervention)

Medium Risk Criteria (rules out clinically important brain injury)

  • GCS < 15 at two hours post-injury
  • Suspected open or depressed skull fracture
  • Any sign of basilar skull fracture (hemotympanum, Raccoon eyes, Battle’s sign, CSF oto or rhinorrhea)
  • Retrograde amnesia to event  ≥ 30 minutes
  • Dangerous mechanism (pedestrian struck by motor vehicle, ejection from the motor vehicle, fall from > 3 feet or > 5 stairs)

The Canadian CT Head Rule (CCHR) only applies to patients with an initial GCS of 13-15, witnessed loss of consciousness (LOC), amnesia to the head injury event, or confusion. The study was only for patients > 16 years of age. Patients were excluded from the study if they had “minor head injuries” that didn’t even meet these criteria. Patients were also excluded if they had signs or symptoms of moderate or severe head injury including GCS < 13, post-traumatic seizure, focal neurologic deficits, or coagulopathy. Other studies have looked at different CDRs for traumatic brain injury including the New Orleans Criteria (NOC). However, CCHR has been found to have superior sensitivity and specificity.

Case Discussion

By applying this rule to the above case, the patient should be considered for imaging due to the mechanism. A fall from standing for an adult patient would constitute a fall from > 3 feet; therefore, although the patient would not likely be high risk and need neurosurgical intervention, the patient might have a positive finding on CT that in many practice settings would warrant an observation admission.

A 20-months-old head trauma: CT or Not CT?

by Stacey Chamberlain

A 20-month-old female was going up some wooden stairs, slipped, fell down four stairs, and hit the back of her head on the wooden landing at the bottom of the stairs. She did not lose consciousness and cried immediately. She was consolable after a couple of minutes and is acting normal per her parents. She has not vomited. On exam, she is well-appearing, alert, and has a normal neurologic exam. She is noted to have a left parietal hematoma measuring approximately 4×4 cm.

Should you get CT imaging of this child to rule out clinically significant head injury?

PECARN Pediatric Head Trauma Algorithm

Age < 2

Age ≥ 2

  • GCS < 15, palpable skull fracture, or signs of altered mental status
  • Occipital, parietal or temporal scalp hematoma; History of LOC≥5 sec; Not acting normally per parent or Severe Mechanism of Injury?
  • GCS < 15, palpable skull fracture, or signs of altered mental status
  • History of LOC or history of vomiting or Severe headache or Severe Mechanism of Injury?

The PECARN (Pediatric Emergency Care Applied Research Network) Pediatric Head Trauma Algorithm was developed as a CDR to minimize unnecessary radiation exposure to young children. The estimated risk of lethal malignancy from a single head CT in a 1-year-old is 1 in 1000-1500 and decreases to 1 in 5000 in a 10-year-old. Due to these risks, in addition to costs, length of stay and potential risks of procedural sedation, this CDR is widely employed given the frequency of pediatric head trauma ED visits. This CDR has the practitioner use a prediction tree to determine risk, but unlike some other risk stratification tools, the PECARN group does make recommendations based on what they consider acceptable levels of risk. In the less than 2-year-old group, the rule was found to be 100% sensitive with sensitivities ranging from 96.8%-100% sensitive in the greater than two-year-old group.

This algorithm does have some complexity and ambiguity. It requires the practitioner to know what were considered signs of altered mental status and what were considered severe mechanisms of injury. In addition, certain paths of the decision tree lead to intermediate risk zones. In these cases, the recommendation is “observation versus CT,” allowing for the ED physician to base his/her decision to image or not based on numerous contributory factors including physician experience, multiple versus isolated findings, and parental preference, among others.

Other pediatric head trauma CDRs rules have been derived and validated; however, in comparison trials, PECARN performed better than the other CDRs. Of note, in this study, physician practice (without the use of a specific CDR) performed as well as PECARN with only slightly lower specificity.

Case Discussion

For purposes of the case study, the patient falls into an intermediate risk zone of clinically important brain injury. However, a sub-analysis of patients less than two years old with isolated scalp hematomas suggests that patients were higher risk if they were < 3 months of age, had non-frontal scalp hematomas, large scalp hematomas (> 3cm), and severe mechanism of injury. Given the large hematoma in the case study patient and a severe mechanism of injury (a fall of > 3 feet in the under two age group), one might more strongly consider imaging due to these two additional higher risk factors.

Siedel Test

A 42 years old male, presents to the ED 1 hour after he was hammering a nail onto a wooden shelf, where the nail flew and strike his left open eye. In an attempt to help, his friend immediately removed the nail. After that, he has been having severe sharp pain and blurry vision in his left eye. On examination, the left eye had poor visual acuity, and he could only perceive light and movement. The pupil was fixed, dilated and non-reactive to light. Right eye examination was normal.

819.2 - eye penetran trauma 2 -siedel sign
819.1 - eye penetran trauma 1

How would you approach to this patient?

To learn more about it, read chapters below.

Read "Eye Trauma" Chapter

Read "Red Eye" Chapter

Quick Read

Globe rupture

It is an ophthalmologic emergency, consisting of a full-thickness injury in the cornea or sclera caused by penetrating or blunt trauma. Anterior rupture is usually observed, as this is the region where the sclera is the thinnest. Posterior rupture is rare and difficult to diagnose. It can be diagnosed through indirect findings such as contraction in the anterior chamber and decrease in intraocular pressure (IOP) in the affected eye. If there is a risk of globe rupture, a slit lamp test with 10% fluorescein must be conducted. Normal tissue is dark orange under a blue cobalt filter; a lighter color is observed in the damaged zone due to a lower dye concentration. Ultrasonography (USG) can be useful in making a diagnosis, especially with posterior ruptures. Computed tomography (CT) sensitivity ranges 56–75%. In cases of anterior globe injuries, USG use, and if there is a risk of a foreign metal body, magnetic resonance imaging, are contraindicated. Prompt ophthalmology consultation is required. While in the emergency department, tetanus prophylaxis, analgesics, bed rest, head elevation, and systemic antibiotic therapy are required. The most commonly preferred antibiotics are cefazolin and vancomycin. Age over 60 years; injury sustained by assault, on the street/highway, during a fall, or by gunshot; and posterior injuries are indications of a poor prognosis.

Siedel test

Seidel test is used to detect ocular leaks from the globe following injury. If there is penetration to the eye, aqueous leakage happens. However, the fluid is clear and hard to identify. Therefore, non-invasive test “Siedel” is used for better visualization of this leakage. Fluorescein 10% is applied to the injured eye, and the leakage becomes more prominent.

To learn more about it, read chapters below.

Read "Eye Trauma" Chapter

Read "Red Eye" Chapter

Selected Orthopaedic Problems and Injuries section is added.

Selected Orthopaedic Problems and Injuries

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To help us to create a global medical student Emergency Medicine rotation database, if your institution/hospital are willing to accept international medical students in Emergency Medicine,

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A tongue bite after seizure

771 - new onset seizure - tong bite

A young man presented after a new onset seizure.

The image/video archive reached to 75K views, and we just added 52 new clinical images today. You can search, find the image you want and use them in your exams, presentations freely. Here is the link of the archive.

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

iEM Image Archive

iEM image/video archive in flickr reached to 67,500 views in the testing period. Thank you for viewing and using them. If you would like to share your resources with the world through the iEM project, you are most welcome; please check “how to contribute” page.

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Depressed skull fracture

735.1i - head trauma - skull fracture
735.2 - head trauma - skull fracture 2

A 31-year-old male presented to the ER after falling from a 3-meter wall. He fell on his face and is complaining of face pain and body aches. He isn’t sure if he lost consciousness. GCS 15/15. Not much history was taken from the patient as he was in excruciating pain. Vitals HR: 105 bpm, RR: 19 bpm, BP: 106/59, Ox. Sat: 100%, Temp: 36.9.

This case is a kind of unusual. Having this amount of depression of the skull and showing almost no neurological abnormality is not happening very frequent.

We hope that you also recognized the air inside in the right image.

To learn more about how to read the CT scan, see the chapter below.

How to read head CT by Reza Akhavan

You may also see below infographic showing a mnemonic about reading head CT in the ED.