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Episode 58: Tendons and Ligaments – Commonly Missed Uncommon Orthopedic Injuries Part 2

Episode 58: Tendons and Ligaments – Commonly Missed Uncommon Orthopedic Injuries Part 2

In part 2 of our round-table discussion on EM Cases with sports medicine guru Dr. Ivy Cheng and orthopedic surgeon Dr. Hossein Mehdian we elucidate some key commonly missed uncommon orthopedic injuries that if mismanaged, carry significant long term morbidity. Injuries of the tendons and ligaments are often overlooked by emergency providers as relatively benign injuries and generally are not well understood.

Syndesmosis Injuries typically occur in impact sports. They are missed in about 20% of cases, as x-rays findings are often subtle or absent. The mechanism, physical exam findings, such as the Hopkin’s Test, and associated injuries are important to understand to help make the diagnosis and provide appropriate ED care.

Distal Biceps Tendon Rupture is almost exclusively a male injury and occurs in a younger age group compared to the Proximal Biceps Rupture. It is important to distinguish these injuries as their management and outcomes are different. The mechanism and physical exam findings of Distal Biceps Tendon Rupture, such as the Hook Test, are key in this respect.

Quadriceps Tendon Rupture is often misdiagnosed as a simple ‘knee sprain’, but should be consideration for surgical intervention. Quadriceps tendon ruptures are more commonly seen in patients older than 40 years and are more common than patella tendon ruptures which are more commonly seen in patients under 40 years of age. Interestingly, up to 1/3 of patients present with bilateral quadriceps tendon ruptures, so comparing to the contralateral knee may be misleading. There is a spectrum of knee extensor injuries that should be understood in order to provide proper care, with the Straight-Leg-Raise Test being abnormal in all of them. This is of the most important physical exam maneuvers to perform on every ED patient with a knee injury. The x-ray findings of these injuries may be subtle or absent, and proper immobilization of these injuries is important to prevent recoil of the tendon.

Patients with calf pain and Gastrocnemius Tears are often misdiagnosed as having a DVT. In fact, one small study showed that gastrocnemius tears were misattributed to DVT in 29% of patients. This confusion occurs because sometimes patients who suffer a gastrocnemius tear report a prodrome of calf tightness several days before the injury, suggesting a potential chronic predisposition. With a good history and physical, and POCUS if you’re skilled at it, needless work-ups for DVT can be avoided.

For well thought out approaches, pearls and pitfalls, to these 4 Commonly Missed Uncommon Orthopedic Injuries, listen to the podcast and read the rest of this blog post….

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Best Case Ever

Best Case Ever 31: Andrew Sloas on Pericardiocentesis

Best Case Ever 31: Andrew Sloas on Pericardiocentesis

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On this EM Cases Best Case Ever, Andrew Sloas, the brains behinds the fabulous PEM-ED podcast tells the tale of a pericardiocentesis gone bad and what he learned from it. Emergency pericardicentesis can be life saving, but it also carries risks. Dr. Sloas reviews the steps to take to ensure that the pericardiocentesis needle is the the correct place to minimize the risk of intubating the right ventricle of the heart. A discussion of errors of omission and ones of commission follows....
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Best Case Ever 30 Rob Rogers’ Mother

Best Case Ever 30 Rob Rogers’ Mother

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I caught up with my friend and education innovation mentor Dr. Rob Rogers at ACEP in Chicago where he told me the tale of his mother's devastating illness - the only EM Cases occurrence of a second Best Case Ever. This powerful story begs many questions, some of which we discuss in the podcast: The importance of considering a lumbar puncture in the setting of altered mental status NYD, cognitive de-biasing strategies and the importance of being a humble patient advocate. We discuss a diagnosis that we should never miss in the ED, how to recognize it early, some pearls and pitfals, as well as how to manage it effectively. We touch how to recover from personal tragedy in anticipation of his upcoming SMACC talk in June 2015. Enough of this.....listen.
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Best Case Ever 29: Drug Induced Aseptic Meningitis

Best Case Ever 29: Drug Induced Aseptic Meningitis

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Dr. David Carr presents his third of EM Cases' Carr's Cases. This series features potentially debilitating diagnoses that may be thought of as 'zebras', but actually have a higher incidence then we might think - and if diagnosed early, can significantly effect patient outcomes. Dr. Carr tells the story of young woman with an MRSA supra pateller abscess who was put on trimethoprim sulfamethoxazole and presents looking very ill with a severe headache. Not only has trimethoprim sulfamethoxazole been implicated in aseptic meningitis, but NSAIDS, immunomodulators and antibiotics have also been implicated. The reason this is so important for ED practitioners to know, is that case reports of drug-induced aseptic meningitis have shown that symptoms will resolve completely within 24 hours, once the offending drug has been stopped. Not only that, but if the patient receives the drug again in the future, they are at risk for a more severe case of drug induced aseptic meningitis.
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Best Case Ever 28: Anti-NMDA Receptor Encephalitis

Best Case Ever 28: Anti-NMDA Receptor Encephalitis

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Dr. David Carr presents his second of Carr's Cases. This series features some potentially life-threatening diagnoses that may be perceived as zebras, but actually have a higher incidence then we might think - and if diagnosed early, can significantly effect patient outcomes. This Best Case Ever is about Anti-NMDA Receptor Encephalitis, a diagnosis that was only discovered in 2005, and has only recently been recognized by the Emergency Medicine community. Anti-NMDA Receptor Encephalitis may mimic a first presentation of schizophrenia or Neuraleptic Malignant Syndrome. It may present with seizure, altered mental status, autonomic instability or movement disorder in the absence of drug exposure. When you are faced with any of these presentations and no other diagnosis seems to fit, do an LP and send the CSF for anti-NMDA receptor antibodies. The time-sensitive treatment is IVIG and steroids. Anti-NMDA receptor Encephalitis is a must know diagnosis for all emergency medicine practitioners. Learn how to pick up this important diagnosis by listening to Dr. Carr's Best Case Ever and following the links to further resources.
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Best Case Ever 27: Pediatric Shock

Best Case Ever 27: Pediatric Shock

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Ottawa this year, I had the pleasure of discussing pediatric shock and sepsis with Dr. Sarah Reid, a good medical school friend of mine from the Gretzky Year ('99) graduating class. I knew back then that she was heading for PEM educator stardom. Lo and behold, she is the now the director of CME at the Children's Hospital of Eastern Ontario and a national PEM speaker extraordinaire. After recording an eye-opening session on Pediatric Fever Without a Source and Pediatric Sepsis, she told me the story of her Best Case Ever where the initial presumptive diagnosis was sepsis. Maximize your learning and submit your questions on 'Pediatric Fever Without a Source' on the Next Time on EM Cases page.
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Quick Links to Recent Emergency Medicine Cases Episodes

Entire EM Cases Library is Free Open Access

Episode 58 Tendons & Ligaments – Commonly Missed Uncommon Injuries P2  with Ivy Cheng & Hussein Mehdian

Episode 56 The Stiell Sessions 1: CDRs & Risk Scales with Ian Stiell & Hans Rosenberg

Episode 55 Weingart-Himmel Sessions 2 – Fluids in Sepsis & Post Intubation Sedation with Walter Himmel & Scott Weingart

Episode 54 Weingart-Himmel Sessions 1 – Preoxygenation & Delayed Sequence Intubation with Walter Himmel & Scott Weingart

Episode 53 Pediatric Point of Care Ultrasound with Jason Fischer, Alyssa Abo, Alex Arroyo & Adam Sivitz

Episode 52 Uncommon Commonly Missed Orthopedic Injuries with Ivy Cheng & Hossein Mehdian

Episode 51 Managing Difficult Patients with Walter Himmel, Jean Pierre Champagne & Ann Shook

Episode 50 Recognition & Management of Pediatric Sepsis and Septic Shock with Sarah Reid & Gina Neto

Episode 49 Effective Patient Communication, Patient Centered Care & Satisfaction with Walter Himmel, Jean Pierre Champagne & Ann Shook

Episode 48 Pediatric Fever Without a Source with Sarah Reid & Gina Neto

 

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