EMU Monthly – December 2015

All the EMU goodness for Dec 2015

  • I know the EMU site has been lagging – we are trying to quicken things up. We are also getting a late start this month, but it takes some time to get the proper muse and writer’s inspiration as well as being intoxicated to crank this thing out. Ezetimibe inhibits the absorption of cholesterol in the intestine.  It works well in combo with statins to lower LDL.  In this NEJM RCT comparing with Simvastatin 40 mg – this med did really lower LDL by 24% and reduced CV events. But even though I am not worthy, I have some problems with this NEJM article.  First of all, we now have stronger statins and weaker ones, and simvastatin is not in the former. Also, CV events included hospitalization for angina – which is very subjective and often not a true CV event. . At least the authors acknowledge that the 24% improvement comes at the cost of a lot more money. (NEJM 372(25)2387) TBTR: Ezetimibe will lower your LDL – well maybe. It will also reduce the weight of your wallet.
  • I hate guidelines. As a matter of fact, I am in favor of prohibiting them from entering the USA. But if you have to deal with them, here are some guidelines on how to deal with – guidelines.
  1. They must be current- think about it- by the time they collate the info and publish the guideline –the articles can already be two years old.
  2. They should answer a specific question in the form of PICO (Population, Intervention, Comparator and Outcome)
  3. Evidence should be high level
  4. Interventions should be specific and not drug classes
  5. Outcomes should be patient oriented and not surrogate endpoints,
  6. Adverse effects must be mentioned,
  7. Strength of interventions must be mentioned (often this is in the appendix where no one looks).
  8. They must not only mention conflict of interests but also what steps they took to see that it wouldn’t affect the evidence.
  9. Mention should be made that these are guidelines and are not absolute, although I doubt that will stop lawyers from looking at them that way

So there you have it image001 (Int Care Mede 41(7)1340)Guidelines tend to bite  youimage003 ) Know how to answer TBTR: know how to read and accept a guideline.

  • Hooray for Hollywood-image004 or actually Santa Monica which is right down the road. This article lets us know that the FDA just approved five new anti MRSA drugs some of which are once a week dosing and one is a once dosing and that is it. (Am J Clinical Derm 16(3)137) While MRSA is not a real consideration in my neck of the woods, it is nice to know that there is some success in the battle against evolving pathogens. TBTR: New exterminator potions for MRSA pests. Quote time- years ago – advice columnists were the rage – and twin sisters Dear Abby and Ann Landers were the best. You’ll find some of these quotes funny, some snappy, some inspiring. And of course they are much more interesting than MRSA. Dear Abby: My boyfriend is going to be 20 years old next month. I’d like to give him something nice for his birthday. What do you think he’d like? —Carol
    Dear Carol: Nevermind what he’d like, give him a tie


Dear Abby: Our son married a girl when he was in the service. They were married in February and she had an 8 1/2-pound baby girl in August. She said the baby was premature. Can an 8 1/2-pound baby be this premature? —Wanting to Know
Dear Wanting: The baby was on time. The wedding was late. Forget it.


  • This very interesting article (actually this journal is known for interesting articles)image005 states that there are very few reasons to give antibiotics IV. It is part of surviving sepsis, but otherwise, you should give oral as soon as possible (PLoS Med 12(5)1825). Bioavailability of oral medications can near 100% especially in quinolones, but the point is well taken. However, this article didn’t and can’t look at the possibility of always giving po unless the patient is unable to take it po. Still many docs get more money for IV meds and others still believe in the Jump start theory”. Do patients want it? TBTR: IV antibiotics- a dinosaur? Dear Abby: Is it possible for a man to be in love with two women at the same time? —Jake Dear Jake: Yes, and also hazardous

Dear Abby: I’ve been going with this girl for a year. How can I get her to say yes? —Don
Dear Don: What’s the question?


  • Hey remember this girl? image006That is one of the original Charlie’s Angels- Kate Jackson – She also was on the rookies (see last month’s EMU letter). OK that isn’t a flattering picture so here she is on the set:  image007This is what she looks like today image008 Here is another oldie but goodie. Chloramphenicol. Rarely (OK, Never) used in the states anymore, this drug was our go to drug for bacterial enteritis and for meningitis. We still use it in cream form but of course everyone is scared of the aplastic anemia it can cause – thought to be at 1 case for every 30000 exposures. (It can be irreversible).  They conclude it is less effective than most antibiotics.(J AntimicChemo 70(4)979) I don’t know what to do with this article. True it is an Israeli article (yea for the home team) but the articles it is based on suffer from being mainly from third world countries (hey, nothing against Papua New Guinea) (what was wrong with the old Guinea??)or used as comparators to newer drugs by pharma. Also the risk ratios are – eh. I think it should still be in your armamentarium- especially as resistance rates to more popular antibiotics get higher. TBTR: Chloramphenicol- is it coming back? Dear Abby: I’ve been going steady with this man for six years. We see each other every night. He says he loves me, and I know I love him, but he never mentions marriage. Do you think he’s going out with me just for what he can get? —Gertie
    Dear Gertie: I don’t know. What’s he getting?

Dear Abby: My wife sleeps in the raw. Then she showers, brushes her teeth and fixes our breakfast — still in the buff. We’re newlyweds and there are just the two of us, so I suppose there’s really nothing wrong with it. What do you think? —Ed
Dear Ed: It’s O.K. with me. But tell her to put on an apron when she’s frying bacon.


  • Tox time. Metoprolol (Lopressor) ODs are treacherous. Oh, yea there is calcium and glucagon but they won’t help much in a massive OD. So we have mentioned in the past the use of lipid emulsion and indeed – in this case report – they used it. But they also used hyperinsulemia/euglycemia therapy. For the uninitiated – they give 1 unit/kg/hour of regular insulin and 200 ml/hr of D10. Indeed this was used in the past for calcium channel OD – also in a case report ( PEC 18(1)36)These are after all case reports so I cannot tell you how much of the miracle was done by lipid and how much by insulin but city can be used in those last ditch efforts (Pharmocther 35(5)E56) TBTR: Another possibility for beta blocker OD. Oh by the way if you are interested in the blonde above – she was Farrah Fawcett – who sadly died from rectal cancer in 2009.

Dear Abby: What’s the difference between a wife and a mistress? —Bess
Dear Bess: Night and Day.

Dear Abby: I have always wanted to have my family history traced, but I can’t afford to spend a lot of money to do it. Have you any suggestions? —M.J.B. in Oakland, Calif.
Dear M.J.B.: Yes. Run for a public office.



  • Yes, so we have our likesimage009  here at EMU, and one of them is sleep deprivation and insomnia) After just one day of sleep deprivation in healthy volunteers, they discovered increased QT durations, decreased myocardial performance indices, decel times and isovolumteric relaxation times. (Pace 38(6)713) What this translates to in patient terms isn’t clear to me, but we have seen in older EMUs that deprivation takes a few days to get over so giving someone a day off after a night shift is not enough. Our nurses aren’t even given that honor TBTR: Being deprived- or depraved – is not good.

Dear Abby: What inspires you most to write? —Ted
Dear Ted: The Bureau of Internal Revenue.

Dear Abby: Are birth control pills deductible? —Bertie
Dear Bertie: Only if they don’t work


  • Another of our specialties here at EMU is bashing Augmentin- most recently seen being used by GPs here in Israel for the treatment of bronchitis (if you ever, ever do that, I will never let you read EMU again) Augmentin can cause serious and even fatal liver injury. This usually occurs in females, and in those taking concomitant hepato toxic drugs such as antimicrobials, hormones and analgesics( I assume that can include paracetomol i.e.- acetaminophen) (Hepato Res 45(6)676) As much as I would love to scar you (boo) after looking over their review of the literature- there were only three reported cases of deadly hepatic toxicity out of 255 serious cases of injury. The denominator is also unknown. I remind you – the only time you really need this drug outside of the hospital is for diabetic foot and infected animal bite wounds. image010BTW it can also cause  pseudomembranous colitis. TBTR: Augmentin: don’t let it kill your patient’s liver. Dear Abby: I know boys will be boys, but my ‘boy’ is seventy-three and he’s still chasing women. Any suggestions? —Annie
    Dear Annie: Don’t worry. My dog has been chasing cars for years, but if he ever caught one, he wouldn’t know what to do with it.
  • Acute Achille’s tendon rupture: what is the best treatment? Whether you have them do surgery or not, the results are the same –that is the same rate of rupture in the future. This is basically due to adhesions which are common after surgery. (Am Fam Phy 91(1)759) I do not know if you have a choice on a complete rupture, but a partial one – conservative treatment is probably just fine. TBTR: Achilles rupture- conservative therapy is probably enough.

Dear Abby: I’m 19 years old and not very experienced, but my mother told me to be careful of men with mustaches. Is there any truth in this? Anita
Dear Anita: Yes … and also be careful of men without them


Dear Abby: I don’t want to appear conceited but I’m forced to admit that I am one guy who has everything. Women are always flocking around me and telling me how good-looking I am and what a marvelous personality I have. I’m beginning to find this pretty annoying and extremely tiring. I just want to live a normal quiet life. How can I dissuade these hopeful females? C.W.
Dear C.W.: Keep talking

  • Really, you should know this. But everyone knows I am in a time warp. Remember – if you are old enough – those mercury thermometers that would break and leave globules of this neat silver liquid on the floor – and if you touched it you would get a whack over the knuckles from the teacher cause it could kill ya, that mercuryimage011 . The absorption though intact skin or intact GI tract is negligible but it makes for a neat x ray.image012 Truth be told, if you aren’t inhaling the vapors –elemental mercury is harmless image013 (the mad hatter of Alice in Wonderland fame, was mad because of the mercury vapors used to process the hats). (Ind J Peds 82(6)573) image014TBTR Mercury from broken thermometers – is only 500-700 mg of Hg- harmless

Dear Abby: When I was going with Irwin he gave me a parakeet, which I taught to say “Irwin.” Well, Irwin and I broke up and now I am going with a fellow named Ronnie. When Ronnie comes over, the parakeet keeps on saying, “Irwin, Irwin,” and of course, Ronnie doesn’t like it. What should I do? Beth
Dear Beth: Either teach the parakeet to say “Ronnie,” or give Irwin the bird.



Dear Abby: My husband has always been very close to his mother and she has never cared much for me. I asked my husband if I was drowning and his mother was drowning which one would he save? He said “My mother because I owe her more.” I am so terribly hurt, Abby. What shall I do? Arlene
Dear Arlene: Learn to swim.


  • Here is another blast from the past. Remember this guy?image015 That is Rick Bukata the founder of Emergency Medical Abstracts and the one responsible for unleashing Father Gregimage016 on the world. This is what Rick looks like today. image015 . Rick has gone on record saying that his urine is sterile (meaning – no bacteria).  However, I am so sorry to correct you, Rick. Urine is not sterile. While that is no surprise in the female of our species, it is a surprise that us men have actually more species of bacteria than woman. However, this is a little boring because most women have the same typical types of bacteria and while they are not the same as men, men also have similar strains bacteria hanging around their urine. (Urol Int 94(4)445). Now this is a Pandora’s box. These were healthy volunteers, and there were not many of them. What was their – excuse me-personal hygiene? How does being healthy change the flora? How significant is this clinically? Can these harmless bacteria become aggressive??I doubt that Rick will comment on this, but I am sure Father has what to say on this fluid subject. I think it was Erma Bombeck who said – never accept a drink form a Urologist- now you know why. TBTR: Urine – is not sterile – even in males.

Dear Abby: My problem is my husband. He wears false teeth — uppers and lowers — and he thinks it’s real funny to take them out at parties and do a Spanish dance using them as castanets. He thinks he is being the life of the party — but I’m embarrassed to death. Should I keep him away from parties, or should I just tell him that he isn’t funny? Marsha
Dear Marsha: Let him have a good time … I think it’s hysterical.


Dear Abby: I am 44 years old and would like to meet a man my age with no bad habits. Rose
Dear Rose: So would I

  • Blow me away (actually that was a pun-you’ll see soon why). This massive 16 country investigator study found a simple but critical point. VAP (ventilator associated pneumonia) is bad and is a killer in post arrest respirator patients. Lower PEEPS , higher tidal volumes, and higher plateau pressures will give you more pneumonias (Crit Care 19:215) Of course meticulous hand cleaning, chlorhexidine washes of the mouth and  avoiding 180- degree position will help took, as we pointed out in the past.  TBTR: Good respiratory management will result in survival of your patients.

Dear Abby: My boyfriend took me out for my twenty-first birthday and wanted to show me a very special good time. I usually don’t go in much for drinking, but since it was an occasion to celebrate, I had three Martinis. During the dinner we split a bottle of champagne. After dinner we each had two brandies. Did I do wrong? Blondie
Dear Blondie: Probably

  • Old folks are always fracturing their shoulders and the best bet will always be – just leave them alone. Operations – in this literature search reviewing going back to 1946 showed that even if it was a four point fracture of the humerus – the operation did little to return them to normal function.(Acta Orth 86(3)280) Don’t mess with the shoulder – you are going to regret it.image017 TBTR: Sling those humeral fractures- that is all they need.

Dear Abby was speechless when these came in:

Dear Abby,
Do you think it would be all right if I gave my doctor a little gift? I tried for years to get pregnant and couldn’t and he did it.

Dear Abby,
A couple of women moved in across the hall from me. One is a middle-aged gym teacher and the other is a social worker in her mid-twenties. These two women go everywhere together and I’ve never seen a man go into their apartment or come out. Do you think they could be Lebanese?

Dear Abby,
What can I do about all the sex, nudity, language and violence on my VCR?

Dear Abby,
I have a man I never could trust. He cheats so much I’m not even sure this baby I’m carrying is his


  • Clinical quiz- does anyone ever get these? Does anyone even try? Doesn’t anyone even care? So there is this fellow in Minnesota (talk about a place no one really cares about) who underwent radio frequency ablation of for the treatment of atrial fibrillation. He comes with fever and seizure.  Blood cultures are positive with bacteria from the GI tract. What happened.(Heart Lung 44(4)314) Here is another hint:image018

Dear Abby,
I am a twenty-three-year-old liberated woman who has been on the pill for two years. It’s getting expensive and I think my boyfriend should share half the cost, but I don’t know him well enough to discuss money with him.

Dear Abby,
I suspected that my husband had been fooling around, and when I confronted him with the evidence he denied everything and said it would never happen again.

  • This is NOT the article that we are looking for. Clean post dermatological surgical wounds do not need antibiotic ointments; petroleum jelly will be enough. I do not know how they knew this considering that wound infection after clean surgeries are rare- but this was a literature search (J Derm Treat 26(2)151) We do not have this luxury of clean wounds in the ED and perhaps we can say that very well cleaned wounds or those from clean sharp items will also need no antibiotic creams but this article cannot prove it. Let’s do the study to prove it, huh guys? TBTR: Antibiotic creams really don’t do much in clean wounds – what about cleaned wounds?

Dear Abby,
I was married to Bill for three months and I didn’t know he drank until one night he came home sober.

Dear Abby,
My mother is mean and short-tempered. I think she is going through her mental pause.

Dear Abby,
You told some woman whose husband had lost all interest in sex to send him to a doctor. Well, my husband lost all interest in sex years ago and he is a doctor


  • Well we have been mentioning Father Greg so we had to bring this opinion piece from the BJGP. Again a blast from the past. image019This was supposed to be Father Greg’s first wife, but he blew it (anyone knows who this is?)  Well the old days you used to be able to fault physicians if they did not act within the accepted medical opinion – the so called Bolam test. This was modified in 1997 in the Bolitho case when it became acceptable to challenge guidelines. But you had to know the guidelines to challenge them. Now with a push of a button – a lawyer can see the medical records anyone of they want (with their permission of course) and as well – the guidelines. They give the math here- you need only contact eight stroke victims in the UK to find one case that did not fit the guidelines – and wham – a suit. They refer this as being electronic ambulance chasing and indeed it sounds like that. (BJGP 65(632):152) image020Just another example of things that will put us more at the computer documenting and documenting and less at the beside.  TBTR: Electronic ambulance chasing – not good for us. image021Abby now gives us some words of wisdom.

Wisdom doesn’t automatically come with old age. Nothing does
– except wrinkles. It’s true, some wines improve with age. But
only if the grapes were good in the first place.”

“If you want children to keep their feet on the ground, put some responsibility on their shoulders.”


  • What do you do with this article? All of us have taken live animals from ears and they had six really bad cases after such extractions – two died from sinus venous thrombosis. They are at a loss as to how this happens and say that only ENTs should take out foreign bodies from the ear- but one of these cases also occurred by an ENT (the patient survived a sinus venous thrombosis) (J Laryn Otol 129(6)540) What kind of bugs were these? The docs that took them out – what kind of conditions and training did they have? This is India so who knows? But kind of concerning – give good discharge instructions! TBTR: Bugs in ear can cause cellulitis, mastoiditis and various other bad things.

People who fight fire with fire usually end up with ashes.”

“The less you talk, the more you’re listened to


  • Can you learn something from this case? I think you can – and the lesson is not that radiologists are idiots. I mean they are, but that isn’t the point here. Contrast reactions – the treatment is epi. We all knew that. But when they asked these radiologists to take an epi vial off the crash cart and give the right dose- only 52% got the IM dose right and only 29% the IV dose. (AJR 205(1)90). OK, I am not being very fair here.  A little less than a quarter of the people studies were nurses. Also, no word on who was ACLS trained. TBTR: Do you know the right dose of IV epi for an allergic reaction? Well let’s get some advice from her twin sister Ann Landers. “Keep in mind that the true measure of an individual is how he treats a person who can do him absolutely no good.”             “The naked truth is always better than the best-dressed lie.”
  • Silica Gel – you know- that packet they put in pill bottles, and other things that need to stay dry – is completely harmless despite the “do not eat” that is printed on them. In this poison center (Israel) they got 546 calls about the packet being swallowed even though it is completely benign. They say it wasted a lot of resources. (IMAJ 17:(604) “Don’t accept your dog’s admiration as conclusive evidence that you are wonderful.”      “Problems are inevitable. Misery is a choice.”
  • This article is critical and it is a bombshell. Why I left it until now because I didn’t want to set off the fireworks this early on. 3 former senior editors (I think two of them were editor in chiefs) of the NEJM give their rather heated opinion on two current editors (including the editor in chief) of the NEJM who feel we are a little too harsh on pharma sponsored studies. They come from the principle that maybe- like many claim – doctors are not influenced by pharma money but it is impossible to know in each case for sure. Judges are supposed to excuse themselves from cases even if they are sure the money they received or the financial interest they have will not influence them- so why shouldn’t researchers? They then take on ghost writing, speaker’s fees, ill-defined consulting arrangements and other wastes of money that distort our relationship with pharma and impose on our independence.(BMJ 350:h2942) They do not mention that these fees are passed on to the public via exaggerated drug costs. Also they obviously did not publish this in the NEJM but in the BMJ whose policy is like theirs. Another journal (JAMA?) may have garnered more debate. TBTR: Pharma influences you – whether you think so or not. Hanging onto resentment is letting someone you despise live rent-free in your head.”    Don’t give up. Keep going. there is always a chance that you stumble onto something terrific. I have never heard of anyone stumbling over anything while he was sitting down”
  • I will mention this article even though EMA mentioned it first, but first of all it is important and secondly – I found the article first. You are going to miss meningitis in kids- progression to meningitis is unpredictable in normal healthy kids. All your CRPS, WBC and pro calcitonin are not going to help you make the diagnosis, but thankfully meningitis is a rare diagnosis. While they will come back and look sick they often will go to a different ED. On the good side however, this miss generally doesn’t cause more mortality.  The best advice for the first visit is that sick kids look sick. And no lab tests will help you. (Ann Emerg Med 65(6) 633)  What they don’t mention is what I learned from Jerry Hoffman years ago- there are two flavors of meningitis- – the fulminant one where nothing you do can really help, and the slower onset which tends to do well no matter what. Bill Mallon mentions this as well, and while I do not know Billy (amend I for sure have a better sense of humor than him – I am willing any time to a competition) he deserves congrats on going to Stoneybrook, where he joins Adam Singer (EMU reader) Scott Weingart (ditto) and Peter Viciellio (who is not) But one of the authors is Baruch Krauss who is a reader. TBTR: Sick kids look sick. Do not worry if you missed that meningitis. “Some people believe that holding on and hanging there are signs of strength, but there are times in life when it takes much more strength just to let go.”    “There are really only three types of people: those who make things happen, those who watch things happen, and those who say, What happened?”
  • Dog ear formation can be prevented by a horizontal mattress suture which is put in with upper side on an angle. (diagonal mattress suture) They claim this works and causes less scarring, but no evidence and not theory why. ( JAAD 73:e27) I will use this opportunity just to mention a great site for all you need for basic and advanced suturing called lacerationrepair.com TBTR: a possible solution to avoid dog ear. image023Some women have the best husbands. Others make the best of the husbands they have.” “Blessed are they who hold lively conversations with the helplessly mute, for they shall be called dentists.”
  • I am not belittling this but really – I don’t have much to say on the subject- Debriefing is important- and they mean debriefing and not defusing which is more along the lines of getting emotions out. Debriefing is more on what went wrong and what can be improved. This is supposed to be constructive without finger positioning (as opposed to a CPC) and should occur soon after the event. They give tools for debriefing and forms and I will say it is pretty practical. (Ann Emerg Med 65(6)690) They do speak about time issues in the ED, this is the chief obstacle to doing this. TBTR: Debriefingimage024 “I have leveled with the girls – from Anchorage to Amarillo.
    I tell them that all marriages are happy
    It’s the living together afterward that’s tough.
    I tell them that a good marriage is not a gift,
    It’s an achievement.
    that marriage is not for kids It takes guts and maturity.
    It separates the men from the boys and the women from the girls.
    I tell them that marriage is tested daily by the ability to compromise.
    Its survival can depend on being smart enough to know what’s worth fighting about.
    Or making an issue of or even mentioning.
    Marriage is giving – and more important, it’s forgiving.
    And it is almost always the wife who must do these things.
    Then, as if that were not enough, she must be willing to forget what she forgave.
    Often that is the hardest part.
    Oh, I have leveled all right.
    If they don’t get my message, Buster,
    It’s because they don’t want to get it.
    Rose-colored glasses are never made in bifocals
    Because nobody wants to read the small print in dreams
  • Myocarditis- you will miss this diagnosis. And it will kill people.  image025 Think you can pick this up with just EKG changes and troponin elevations? Wrong.image026 Actually, the opposite is more common- you will think it is an MI when it is really myocarditis – which has been shown to be the case very frequently on autopsy studies.  Endomyocardial biopsy is the gold standard but it needs good hands and – check this out- if you do 17 biopsies  you only get to a sensitivity of 80%- not much of a gold standard.  The other option is gadolinium enhanced MRI.  This is still being studied but it will miss borderline myocarditis (no one know if that matters) and chronic endocarditis. Seems the best bet is clinical suspicion – such as pain in a young person who had a viral prodrome. (Int J Card 191:211) TBTR: I go with clinical suspicion in myocarditis diagnosis – with blood cultures and MRI. “Blessed are they who hold lively conversations with the helplessly mute, for they shall be called dentists.”   “at every party there are two kinds of people – those who want to go home and those who don’t. the trouble is, they are usually married to each other.”

25)        I just want you to know.  Under the new headache classifications – there is a vestibular migraine- headache and dizziness. Unfortunately, it can be confused with many other syndromes. So here we go image027 Meniere’s disease – the hearing loss – present in both conditions- is worse in Meniere’s.  BPV-Vestibular migraine has longer individual vertigo episodes but it goes away faster (no more than a few days) Vestibular neuronitis has a viral prodrome and worse nystagmus. Headache is less frequent. Central vertigo (VBI) the vertigo is less prominent and less violent – there are more associated neuro symptoms (They do not mention HINTS) (Curr Pain Headache Rep 19:31) TBTR: Vestibular migraine – it exists and is quite common. The Lord gave us two ends — one to sit on and the other to think with. Success depends on which one we use the most

  • Letters: next month???
  • The answer in 14 was a fistula between the esophagus and the atrium. Indeed the CT and echo (TTE) were not helpful –this was only picked up on UGI endoscopy after a bout of hematemesis. These patients usually have some kind of neuro and septic features, Hard diagnosis to pick up. And 16- that was Betty Grable – a famous pinup in the thirties. I think Father Greg is still heartbroken about her rebuffs- – made him start drinking Mogen David wineimage029

EMU LOOKS AT: Orthopedic misses

OK, so this is written from the radiologist side which is not really relevant in my neck of the woods where the bone guys read their own films. But these are misses which you really can’t make. The sources for this essay are Radiology Clinics NA 53:717 and ibid 53:737. This is going to be a little tough – I can’t use the pictures from the article and the stuff from Google may not be so nebulous.

Upper Extremity – commonly missed fractures.

  • Just before we start – this article – by the rays guys – says we-EPs have a miss rate of about 8% – doesn’t sound too bad.
  • Isolated fracture of the greater tuberosity:image031 sometimes this can be more subtle – like just a notch 3-5 mm. Fractures may need surgery. Especially if they are athletes
  • Non displaced radial head fractures- these do not bother me too much since we don’t even cast them anymore but in any case you should know about the fat pad signs- the posterior in a normal individual is not seen and the anterior is next to the bones.image033 In this normal elbow – it is a black strip near the humerus.  In a fracture or tendon tear- basically any effusion – you will see the posterior black stripe and you will see the anterior black stripe away from the bone- the sail sign. image034This sign is actually has a 95% sensitivity.


  • Chauffeur’s fracture: image036This is of the radial styloid – look closely – 2 mm can cause a lot of posttraumatic arthritis if missed.
  • Scaphoid fracture- I do not have to tell you much here – the more proximal – the less blood supply. Do navicular views; do repeat X rays (cheap way) or an MRI (the expensive way).
  • Volar plate fractures I do not think they are so subtle but you will miss them if you do not look over the x-ray carefully. This one is at the base of the second phalanx. These can lead to arthtiis and joint instablility.image038
  • I going to skip coracoid and acromion fractures- they are rare but hard pickups- see the article. They rarely need any treatment.
  • Carpal metacarpal fractures and dislocations – and both –I actually have seen this – in a snowmobile accident rollover in Sault Ste. Marie Michigan. A place so cold that even Father doesn’t venture thereimage039This can be subtle – especially MC IV and V and is best seen in lateral.  image041image043 These do need a reduction but closed reduction doesn’t hold too well. As you can see from these pictures The AP is not that revealing.
  • Hamate and triquetrium fractures are also subtle but again – are rare and do not usually need operative intervention unless they are dislocated – and those you are not going to miss.
  • OK, I was against it, but we but all-the editors of EMU voted and I loss- which is pretty amazing since I am the only editor. You can reduce a shoulder- you of course know how- but look for post reduction fractures. Hill Sachs – which is a notch on the humeral head (doesn’t bother us too much) and Bankart lesions (a fracture of the lower gleniod- which may bother us- recurrent dislocations) can happen.image045
  • I know you know the Itialians of the forearm. The obivous ones are Monteggias and Galeazzis fractures. But here is one that you won’t like. Essex Lopresti. This is a disruption of the distal radio ulnar joint in the setting of a comminuted impacted radial head fracture. Early surgery gives better results- so do not forget this one I could show you this one, but you will need a CT.
  • The last in the upper extremity is – what I was told but I haven’t found an article on this – the most common cause for malpractice payout on a hand problem not involving a fracture. This would be a perilunate and lunate dislocations- You need to look for the ball in the cup – if it isn’t – on lateral –it is one of these and needs treatment to avoid persistent pain and disability. Here is a normal lateral view- the ball is in the upper part of the picture, the cup below.image047  Next the dislocations. Perilunate:image049 and lunate:image051

Lower Extremity Easy Misses:

  • Look it (I have a patient that says this all the time – it is annoying) you will miss hip fractures because they can be occult. Ramus factures and femoral head fractures as well. I cannot make you better at these- you just have to pull the trigger on CT if the patient cannot walk and plain films are normal.
  • Femoral neck stress fractures are just sclerosis in the area of the femoral neck.image053 A related fracture is the bisphosphonate insufficiency fracture which looks like an enodososteal elevation of the femur- like a volcano – use your imagination.image055
  • There are a few things in the knee – most are stuff that are of no consequence – but in ACL injuries there can be an avulsion of the tibial eminence (just like in kids with Osgood Schlatters). ACL injuries can also cause impacted condypatellar sulcus. I won’t show pictures of these – just think of them when you have a complete ACL. ACL usually presents with a large effusion and the knee may be unstable.
  • Segond fracture- I missed this one once. This is an avulsion fracture of the tibial plateau.image057 Actually I didn’t miss a Segond fracture but a fracture of the tibia plateau. image058Don’t miss this.  This can require surgical treatment. Alright, I was only joking. Here is the more representative fracture.image059
  • Ankles – do not forget a fracture of the posterior lip of the tibia. – the tibial malleolus fracture.
  • Tillaux Fractures are best seen on lateral. They are avulsion fractures of the anterior tibia tubercle.image061
  • Lis Franc’s – we discussed this in an essay in the past- use the search function
  • Many more rare and obscure fractures – but they are of little consequence- you can always pull the article (or pull my chain)


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