Emergency Procedures: Shoulder Immobilisation

emergency procedures-shoulder immobilisation

Indications

  • Shoulder dislocation (post reduction)
  • Acromioclavicular injuries (grade 1-3)
  • Fracture of humeral head, greater tuberosity or clavicle

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Finger Splint

Indications

  • Fractures of distal and middle phalanx
  • Volar plate injury
  • Post reduction of dorsal PIP dislocation
  • Mallet injury (distal phalanx extensor tendon rupture with or without avulsion fracture)

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Short Leg Backslab

emergency procedures-short leg backslab

Indications

  • The distal tibia and/or fibula fractures
  • Ankle injuries
  • Tarsal injuries
  • Metatarsal injuries

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

Emergency Procedures: Long Leg Backslab

emergency procedures-long leg backslab

Indications

  • Tibia and/or fibula shaft fractures
  • Knee and patellar fractures
  • Distal femur fractures

This video has been provided by Emergency Procedures App developers (Dr John Mackenzie and Dr James Miers) in order to help medical students, interns in training. Please visit the video source or Emergency Procedures app for more procedure videos and information. 

Contributors

Dr John Mackenzie

Dr John Mackenzie

Dr John Mackenzie MBChB , Dip MSM, FACEM . Staff Specialist Emergency Medicine, Consultant Hyperbaric Medicine Specialist, at Prince of Wales Hospital. Known for cycling endlessly for no apparent reason. 20 years of developing virtual learning for clinicians at all levels.

Dr James Miers

Dr James Miers

Dr James Miers BSc BMBS (Hons) FACEM, Staff Specialist in Emergency Medicine, Prince of Wales Hospital, Sydney. Passion for gypsy jazz and chess. Lead author of Lead author of Emergency Procedures App.

Further Reading

iEM Image Feed: Plateau Fracture

iem image feed

A 60-year-old man known to have DM type 2 was brought by the family as a camel hit his knee. He was not able to walk on it at the scene and in ED. It was swollen with no open wound.

Tips
Although patients come with isolated injuries, we always have to make sure that they do not have other injury findings. Therefore, approaching systematically to the patient is important. At this moment, please remember primary and secondary surveys of multiple trauma. The animal attacks may create multiple injuries on patients, and they should be evaluated as multiply injured patients. After you ruled our multiple or life, organ, extremity threatening injury, you can deep dive into isolated injuries. In this case, knee injury after a direct hit.

Of course, inspection and palpation are essential in every extremity injury. Evaluating the patient for neurovascular problems and range of motions are applied in almost every extremity trauma. But sometimes, clinical presentations or findings can be subtle and you may need a better tool. In these case, we recommend using Ottawa Knee Rules.

The image shows tibia plateau fracture on AP knee x-ray.

885.1 plateau fracture
885.2 plateau fracture copy

Additional reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Plateau Fracture," in International Emergency Medicine Education Project, April 7, 2021, https://iem-student.org/2021/04/07/plateau-fracture/, date accessed: December 5, 2023

iEM Image Feed: Radius and Ulna Fracture

iem image feed radius and ulna fracture
radius and ulna fracture

Her father brought a 9-year-old girl due to deformed right extremity. He was playing at home and fell from a hight on his hand. No open wounds. No past medical and surgical. Vaccination: up to date.

Examination: radial pulse is intact. He can move the fingers but with limitation due to pain. Sensation is normal. The X-ray showed both radius and ulna fracture. The patient underwent procedural sedation with IV ketamine, and the reduction was made with ortho oncall.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Radius and Ulna Fracture," in International Emergency Medicine Education Project, March 31, 2021, https://iem-student.org/2021/03/31/radius-and-ulna-fracture/, date accessed: December 5, 2023

iEM Image Feed: Humerus Shaft Fracture

image feed
humerus fracture
humerus fracture 2

The EMS brought a 39-year man as his right upper extremity was stuck in a machine in a factory where he works. He came with deformity and severe pain in his right arm. Pain management was given. He received tetanus toxoid as well. X-ray shows oblique humeral shaft fracture with shortening and angulation. He underwent procedural sedation to reduce it.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Humerus Shaft Fracture," in International Emergency Medicine Education Project, March 17, 2021, https://iem-student.org/2021/03/17/humerus-shaft-fracture/, date accessed: December 5, 2023

iEM Image Feed: Mandibular Fracture

image feed
mandibular fracture

A 39-year-old woman presented to ED with mouth pain. She was cleaning the bathroom and suddenly slipped and fell. She hit her mandible with the floor. She was able to speak minimally—no avulsed teeth. She had teeth 23 and 24 subluxations.

This is a high energy impact trauma. Ensure that you evaluate the patient systematically for trauma and not forget to pay attention to a neck injury. Violence, assault, partner abuse should be in your mind. Specific mandibular and panoramic imaging may give excellent views for diagnosis. In some cases, CT may be necessary to evaluate the maxillofacial injury. Besides, know the teeth universal numbering. If you see this kind of damage in the examination, always rule out an alveolar fracture.

Cite this article as: iEM Education Project Team, "iEM Image Feed: Mandibular Fracture," in International Emergency Medicine Education Project, March 3, 2021, https://iem-student.org/2021/03/03/mandibular-fracture/, date accessed: December 5, 2023

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: December 5, 2023

I woke up like that! – Bilateral Shoulder Pain

bilateral shoulder pain

Case Presentation

A 35-year-old male presented to fast track complaining of bilateral severe shoulder pain for one-day duration. He reports waking up like that, and not being able to move his shoulders much due to the pain.

He denied any recent falls, injuries, or direct trauma to his shoulders. He also denied any fever, rashes, skin changes, headaches, numbness or weakness. No further findings found upon review of systems. Past medical history revealed a history of epilepsy. Otherwise, he’s not on any medications and denies any known allergies.

Physical examination showed slim male, with flattened anterior shoulders and normal inspection of the skin overlying his shoulders. He had internally rotated upper extremities, flexed elbows, and arms held in adduction. Upon attempts on any passive or active test of the range of motion, he experienced reluctance and pain on external rotation or abduction of his shoulders. Bilateral Shoulder X-rays were obtained.

shoulder dislocation and fracture 1
shoulder dislocation and fracture 2

This patient had bilateral posterior shoulder dislocation, with associated fractures.

    • Posterior shoulder dislocations make up 2-4% of shoulder dislocations.
    • May go undiagnosed and often missed on physical exam and imaging
    • Epileptic seizures or electrical shocks, sports injuries are the most common causes.
    • Subtle signs on AP X-Ray include:
        • Light Bulb Sign: Fixed internal rotation of the humeral head, makes the greater tuberosity anterior, giving a symmetrical appearance of the humeral head, that looks like a light bulb.
        • Empty Glenoid Sign: Humeral Head and Glenoid fossa widened articular space
        • Trough Sign: Vertical Line on AP, can indicate compression fracture of the humeral head medially.
    • In suspected Posterior Shoulder Dislocations, you should always get multiple views, including Anterior-Posterior (AP), scapular (Y), and Axillary Views.
    • Rounded posterior shoulder.
    • Prominent coracoid and acromion.
    • Palpable posterior humeral head.
    • Flattened anterior shoulder contour.
    • Neurovascular injuries
    • Rotator cuff tears
    • Osteonecrosis of the humeral head
    • Recurrent posterior shoulder instability or re-dislocation
    • Joint stiffness and post-traumatic osteoarthritis
    • You need to evaluate each case separately. The cases like this patient, with associated fractures, can complicate your management, and hence consulting orthopedic services would be advised, as surgical interventions should be evaluated.
    • If closed reduction fails, usually open reduction is pondered by subspecialty, especially in cases with extensive damage to the humeral head.
    • In cases with no associated fractures, the approach is the reduction of the dislocation. Most of them would require procedural sedation and analgesia.
    • Consider discussing options of procedural sedation and analgesia, with or without intraarticular blocks with your attending, for better and successful procedures, and minimal pain for your patient. The most convenient procedure options should also be discussed with patients, and consent should be taken. 
    • Patients would require pre and post-reduction neurovascular examination and X-rays.
    • Make sure your patient is examined again after the procedure, assessing the stability of the joint for regained full range of motion. 
    • Shoulder immobilization and follow up care plans with orthopedics services should be arranged.
    • Don’t forget, patients with known epilepsy, non-adherence or uncontrolled seizures have to be evaluated as well, and referred to appropriate neurology evaluation.

Case Reflections

  • Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations.
  • Bilateral fracture-dislocation is even rarer, with a few cases reported in the literature.
  • In the rare case of an asymmetrical bilateral dislocation, attention may be distracted to the more evident lesion, which is the anterior dislocation. This may lead to delayed diagnosis, especially in an unconscious patient in a post-ictal state.
  • In the present case, open reduction and internal fixation was performed.

References and Further Reading

  1. Roberts & Hedges Clinical Procedures in Emergency Medicine (6th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 49
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed) 2011. New York. McGraw Hill Companies Inc. – Chapter 268
  3. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 53
  4. Wikem – Posterior Shoulder dislocation: https://www.wikem.org/wiki/Posterior_shoulder_dislocation
  5. Canadiem – Posterior Shoulder Dislocation: Radiographic Evidence : https://canadiem.org/posterior-shoulder-dislocation-radiographic-evidence/ 
  6. Meena S, Saini P, Singh V, Kumar R, Trikha V. Bilateral anterior shoulder dislocation. J Nat Sci Biol Med. 2013;4(2):499–501. doi:10.4103/0976-9668.117003S – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783813/
  7. Sharma A, Jindal S, Narula MS, Garg S, Sethi A. Bilateral Asymmetrical Fracture Dislocation of Shoulder with Rare Combination of Injuries after Epileptic Seizure: A Case Report. Malays Orthop J. 2017;11(1):74–76. doi:10.5704/MOJ.1703.011 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393121/

Acknowledgement

Credit and acknowledgment for Dr. Eelaf Elhassan for sharing the case.

Cite this article as: Shaza Karrar, UAE, "I woke up like that! – Bilateral Shoulder Pain," in International Emergency Medicine Education Project, December 13, 2019, https://iem-student.org/2019/12/13/bilateral-shoulder-pain/, date accessed: December 5, 2023

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Torus Fracture – Diagnosed with ultrasound

torus fracture

Case Presentation

A 9-years old male patient brought to the ED by his parents because of the right forearm pain. The patient is alert, oriented, and moderately in distress. He described that he stepped on the ball and fell while playing soccer with his friends. He denies any other injury, loss of consciousness, etc.

Physical Exam

Torus Fracture - right arm 2

The patient complaints right forearm pain, especially distal 1/4 of the radius. There was no deformity or swelling recognized on inspection. 

Torus Fracture - right arm 1

The patient refuses any movement on the right arm because of pain during the movement, especially in rotational movements. He prefers to stay in the rest position, as shown in the picture.

There was no visible deformity and swelling in the inspection. However, the patient described palpation tenderness over the forearm, especially point tenderness over the distal 1/4 – 1/5 of the radius. The patient also described minimal pain on elbow and wrist movements. The neurovascular examination was unremarkable. There are no other findings regarding trauma. Patient parents deny any disease, medication, operation, etc. He has received 250 mg paracetamol in the school after consultation with the family. However, he still shows distress because of pain.

After the physical exam, 200 ibuprofen was given. X-ray is planned, and musculoskeletal ultrasound was applied while he waits for an X-ray.

We used Butterfly iQ to investigate the radius by using musculoskeletal settings. The ultrasound showed periosteal discontinuity with a 2-3 mm step-off sign at the distal radius. 

Diagnosing fractures with ultrasound

Ultrasound showed high pooled sensitivity (91%) and specificity (94%) (Schmid et al., 2017). It is a very effective modality, especially in the detection of long bone fractures such as humerus, forearm, tibia, fibula, etc.

In forearm fractures, its’ sensitivity is between 64 and 100%, its’ specificity is between 73-100% (Katzer et al., 2016). Besides, ultrasound provides 25 minutes earlier diagnosis advantage compared to other modalities, namely X-rays. Ultrasound’s effectiveness has elbow, been shown in many articles, its’ best performance is on diaphysis fractures of long bones (Weingberg et al., 2010).

After the detection of Torus (Buckle) fracture by ultrasound, the patient was sent to X-ray in order to investigate elbow, forearm and wrist in more detail. X-rays showed Torus fracture at the distal radius, which the diagnosis aligned with the ultrasound result.​

Torus Fracture - right arm 4

Torus Fracture - right arm 3

AP X-ray showed minor periosteal step-off/bulging on both sides. Lateral X-rays showed periosteal discontinuity with a 2-3 mm step-off on the dorsal side of the radius.

The final diagnosis of the patient was Torus (Buckle) fracture.

A long arm splint was applied in the ED because of his elbow and wrist pain. The patient discharged with pain medication, ice and elevation recommendations. On the 4th day, the patient visited the orthopedic clinic, and his splint changed to short arm splint. He was pain-free on the elbow and wrist.

References

  1. Schmid GL, Lippmann S, Unverzagt S, Hofmann C, Deutsch T, Frese T. The Investigation of Suspected Fracture-a Comparison of Ultrasound With Conventional Imaging. Dtsch Arztebl Int. 2017 Nov 10;114(45):757-764. doi: 10.3238/arztebl.2017.0757. PubMed PMID: 29202925; PubMed Central PMCID: PMC5729224.
  2. Katzer C, Wasem J, Eckert K, Ackermann O, Buchberger B. Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation. Pediatr Emerg Care. 2016 Jun;32(6):401-7. doi: 10.1097/PEC.0000000000000446. Review. PubMed PMID: 26087441.
  3. Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010 Aug;41(8):862-8. doi: 10.1016/j.injury.2010.04.020. Epub 2010 May 13. PubMed PMID: 20466368.
 
Cite this article as: Arif Alper Cevik, "Torus Fracture – Diagnosed with ultrasound," in International Emergency Medicine Education Project, November 6, 2019, https://iem-student.org/2019/11/06/torus-fracture-diagnosed-with-ultrasound/, date accessed: December 5, 2023

What is the name of this fracture?

In case you didn’t encounter a trauma patient today!

674.4 - C1 fx

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