Ottawa Ankle Rule

Case: 32 year old biker hit by slow moving car. Walking with limp and pain at L ankle/foot.

Tapa: The often referred to Ottawa Ankle/Foot Rule can help guide clinical decision making on whether or not imaging is needed.

Ottawa Ankle Rule:

Pain in malleolar zone and (any of the following)

• bone tenderness along distal 6 cm of posterior tibia
• bone tenderness along distal 6 cm of posterior fibula
• Cannot weight bear for 4 steps in Emergency Department

Ottawa Foot Rule:

Pain in midfoot and (any of the following)

• bone tenderness at base of 5th metatarsal
• bone tenderness at navicular bone
• Cananot weight bear for 4 steps in Emergency Department

Miscellaneous notes:

• Ottawa Ankle/Foot Rule is far more sensitive than specific. Therefore, if patient does not fit any criteria in Ottawa Ankle/Foot Rule, they likely do not need an x-ray
• The rule cannot be applied to pregnant women, children <>
• It is also worthwhile to palpate the proximal fibula after ankle injury, checking for a Maisonneuve fracture, and to palpate between the 1st and 2nd MTP checking for a Lisfranc Fracture/Dislocation.
• In 5th metatarsal injuries it is important to recognize the difference between a Jones and Pseudo-Jones fracture, (the former being > 1.5 cm), as this distinction will change the course of management.

Treatment of Cluster Headache

Case: 29 year old male presents with new onset gradually worsening pain located behind R eye. Associated sweating and Nasal Congestion.

Tapa: When working up headaches, the H&P can help separate out the benign from the concerning.

Concerning signs & symptoms include:

• Fever, Meningeal signs, Photophobia, AMS, Syncope, Sudden Onset/Worst HA of life, Trauma, HTN with DBP > 120, unilateral neck pain, signs of glaucoma, or neuro deficits

In this case, the patient has some classic presenting symptoms of a Cluster Headache. Although Cluster Headaches typically present in men in their 40s, they have been reported in both infants and the elderly. Classic signs & symptoms include sudden onset unilateral pain behind the orbit with associated lacrimation.

If you suspect a Cluster Headache, start the patient on Oxygen before presenting the case. The risks and expense of giving oxygen are relatively low. By starting the patient on O2 you will potentially decrease the time of their ED stay (not to mention you will impress your attending/resident)!

If the Headache resolves with oxygen, this is sufficient for diagnosis of a cluster headache. The patient should follow up with a neurologist as an outpatient. If the symptoms do not resolve, consider other therapeutic medications, or consider re-addressing your differential diagnosis.

Indications for Head CT in Minor Pediatric Head Trauma

Case Presentation:

HPI: 6 yo male presents s/p un-helmeted fall from bicycle. Fall unwitnessed, mom reports child came running inside immediately, crying, holding head. Applied ice to developing hematoma, child back to playing with siblings in 15-20 minutes. Pt presents to ED 6 hours after fall- urged to seek treatment by NP over phone when mom called concerned that child "acting funny" at bedtime. Asking to "wear shoes in bed," claiming he saw "pasta in his sister's hair," that it "was time to wake up." Per mom, no change in level of alertness, no nausea/vomiting, no complaints of HA or changes in vision.

Exam: VS- 110/65 76 12 37.1 99%RA
Gen- AAO x3, NAD, laughing, smiling, answers questions appropriately
HEENT- 2cm boggy hematoma above R eye, PERRL, EOMI, no nystagmus, no papilledema, TMs benign, no Battle's sign, nares and oropharynx benign
Neck- supple, full ROM, no spinous process tenderness
Neuro- CN II-XII intact, no focal deficits, finger-nose-finger with no dysmetria, able to run up and down hall without difficulty


Clinical Question: Should this child receive a head CT?

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Evidence:

Osmond, M et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injuries. CMAJ 2010 Mar 9;182(4):341-8

Prospective study conducted at 10 Canadian Pediatric EDs
-3866 subjects age 0-16 with minor head trauma
-Identified key variables of hx and exam associated with abnormal findings on head CT and/or need for neurosurgical intervention
-CATCH rule 98.1% sensitive and 50.0% specific for CT findings/need for intervention
-requires additional prospective validation

Radial Head Fracture in the Adult

Case: 62 year old woman presents after tripping on sidewalk and falling on outstretched hand. No LOC. Left elbow hurts to move. No other injuries or complaints.

Tapa: Radial head fractures are common in adults falling on outstretched hands, but can be difficult to detect on x-ray.

A focused physical exam should include:

• Distal skin examination, capillary refill, radial/ulnar pulses.
• Upper extremity sensation, motor, strength testing
• Upper extremity nerve function can be tested as follows: A-OK (median), crossed fingers (ulnar), thumbs up (radial)
• Active/Passive ROM testing including: pronation/supination, wrist & elbow extension/flexion
• Palpation feeling for point tenderness and/or displacement in entire upper extremity (a rule of thumb with orthopedic injuries is to always check the joints proximal and distal to the site of suspected injury).

At this point you will most likely need an x-ray to confirm your suspicions. Radial head fractures can be classified into three types radiographically. For the purposes of this conversation we will focus on Type 1 fractures, as they are non-displaced, and often the most difficult to detect.

Here you can see a "normal" lateral film of the elbow. The fat pad lines the sinovial fluid in the joint. After trauma to the elbow, the synovial fluid can cause this area to expand, and thus the fat pad can be an indirect marker of type 1 radial head fractures (especially if no fracture in the bone can be appreciated).

Here is an example of displacement of the anterior fat pad, otherwise known as the "sail sign". Remember, this is an indirect sign of trauma, and does not confirm a diagnosis of radial head fracture. Use wisely with your clinical suspicion!












In this example, you can again see the "sail sign". Additionally, you can see a posterior fat pad (marked with arrow). Presence of a posterior fat pad is always abnormal and is the most sensitive radiographic finding for a radial head fracture.













Any suspicions of distal radial/ulnar injuries should warrant wrist films as well.

After examination and radiographs you may still be unsure as to whether the patient has a type 1 radial head fracture or not. Rest assured, the treatment is the same. The patient should be given medication for their pain, placed in a sling, and instructed to mobilize their arm with range of motion exercises after 1 week. They should follow up with an orthopedist, and if any suspicion lingers as to whether or not their is a fracture, radiographs can be repeated at this time as evidence of a fracture will be more apparent.

(Images courtesy of: http://www.wikiradiography.com/)

Assessing the Intoxicated Patient

Case: 40 year old male presents via EMS after being found "sleeping" on the sidewalk. Smells of EtOH, difficult to arouse, disheveled appearance. Electronic records show 7 recent visits related to EtOH with no hospital admissions.

Tapa: Awakening this man could agitate him, creating a difficult scenario for the entire ED staff. In a busy environment, it would be easy to let this man "sleep it off", but the responsibility is on the Emergency Physician to ensure there is no underlying pathology. It is imperative to attempt an initial examination, at the very least so as to have a baseline to compare to on later exams.

At a minimum, intial examination should include:

• Vital Signs and Fingerstick Blood Glucose
• A+O and Glasgow Coma Scale
• If possible, asking what/how much the person had to drink and if other substances were used as well (i.e. cocaine, prescription meds, etc.). Ask questions related to pain.
• Undress patient and examine completely for lacerations, abrasions, obvious deformities, and trauma (especially craniofacial).
• Check for PERRL.
• Perform Cardiac, Respiratory, Abdominal exams (note epigastric tenderness: think pancreatitis work-up)
• Make sure patient can move all 4 extremities, either by command or in response to pain.

If the above examination is unremarkable and you are fairly confident based on the clinical picture that the patient's altered mental status is secondary to Alcohol, the mainstay of treatment is observation & reassessment. IM Thiamine/Folate can be considered, but in general, labs, tox screens, and IV Fluids are unnecessary.

Alcohol is metabolized in the liver via Zero-Order Kinetics at a rate of approximately 1 drink/hour (faster in chronic alcoholics). Reassess the patient in several hours. If the patient is showing improved mentation, continue with your history & physical. If the patient has not improved, further workup including Head CT may be warranted.

The patient can be discharged when they are A+O x3, have a steady gait, and have no new complaints.