emergency medicine orthopedics: Recent Episodes
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Triquetrum chip fractures, scapholunate injuries, hook of the hamate fractures, and of course, scaphoid fractures can be easily missed with serious consequences for our patients. In this part 2 of our 2-part podcast series on wrist injuries we highlight the "Big 4" most commonly missed and mismanaged carpal bone injuries, elucidating the key historical, physical exam and x-ray findings, as well as management strategies...
The post Ep 190 Carpal Bone Injuries – The Big 4 appeared first on Emergency Medicine Cases.
In this part 1 or our 2-part podcast series on wrist injuries Dr. Arun Sayal and Dr. Matt DiStefano answer such questions as:when should we suspect a DRUJ injury, why is it important to pick up DRUJ injuries in the ED, and how does it change our management? Why is the lateral x-ray view so important in picking up commonly missed wrist injuries? When it comes to distal radius fractures, how are Colles vs Barton's vs Smith's fractures managed differently in the ED? What are the 2 key x-ray signs we should look for on the AP and the 2 key x-ray signs we should look for on the lateral for every wrist injury? and many more...
The post Ep 189 Commonly Missed and Mismanaged Wrist Injuries appeared first on Emergency Medicine Cases.
On this month's EM Quick Hits podcast: Anand Swaminathan on the role of methylene blue in septic shock, Nour Khatib on jaw dislocation reduction techniques, Hans Rosenberg on a phenotypic approach to Crohn's disease emergencies, Gil Yehudaiff on evidence based analgesics in renal colic, Brit Long on the importance of inhaled steroids for asthma, and Andrew Petrosoniak on the "lethal diamond" in polytrauma patients and the current state of hypocalcemia in bleeding trauma patients...
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The post EM Quick Hits 51 – Methylene Blue in Septic Shock, TMJ Dislocation, Crohn’s Disease, Analgesia for Renal Colic, Inhaled Steroids for Asthma, Hypocalcemia in Bleeding Trauma Patients appeared first on Emergency Medicine Cases.
You are working the ambulatory section of your ED and evaluating a 6-year boy with a possible distal radius injury. He lives with autism spectrum disorder and is uncomfortable in X-ray rooms, and you wonder if there is a role for PoCUS to help exclude a fracture. With expert clinical commentary by Dr. Arun Sayal and Research Methodology Hot Take by Dr. Shelley Mcleod...
The post Journal Club 4 PoCUS or X-ray for Distal Forearm Fractures appeared first on Emergency Medicine Cases.
Do not let a negative X-ray rule the day! Like almost all medical tests X-rays are far from perfect and should be ordered and interpreted only in the context of a thorough history and physical exam. In this 2nd part of our 2-part series on orthopedic x-rays with Dr. Arun Sayal and Dr. Yatin Chadha we discuss the pitfalls of obtaining and interpreting orthopedic X-rays, when orthopedic X-ray decision tools lead us astray, how understanding the concept of central ray helps dictate how we should order X-rays and interpret them, how the ring structure concept of the forearm and lower leg can remind us where to look for a second injury, when we need 3 views vs 2 views, when extra views like the clenched fist view and weight bearing views are indicated, why we should always look at the lateral view first, the limitations of ultrasound and CT in long bone and joint injuries and more...
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The post Ep 176 Orthopedic X-rays Master Class – Pitfalls in Obtaining and Interpreting MSK X-rays appeared first on Emergency Medicine Cases.
In this main episode podcast, Dr. Arun Sayal creator of the CASTED course and Dr. Yatin Chadha a radiologist with a fellowship in MSK radiology, join Anton for Part 1 of 2 podcasts on Emergency Orthopedic Injuries. This episode focuses on a differential diagnosis of MSK injuries that are occult to X-ray with the help of the SCARED OF mnemonic. It ensures we pick up all the “can’t miss” diagnoses that can be easily overlooked when we do not integrate a pointed history and physical exam with the X-ray in front of us. Essentially, we discuss ‘when X-rays lie’ and offer up a variety of clinical pearls and pitfalls in assessing patients in the ED with MSK presentations…
The post Ep 175 Emergency Orthopedics Differential: SCARED OF Mnemonic – When X-rays Lie appeared first on Emergency Medicine Cases.
In this month's EM Quick Hits podcast: Arun Sayal on the nuances of assessment for scaphoid fractures, Justin Morgenstern on the evidence for therapeutic hypothermia post-arrest and the TTM2 trial, Sarah Reid on HEADS-ED mental health screening tool for children, youth and young adults, Andrew Petrosoniak on pelvic trauma and pelvic binder tips and pitfalls, Michelle Klaiman on what we need to know about Kratom and Anand Swaminathan on why femoral lines are often a great central line choice...
The post EM Quick Hits 30 Scaphoid Fracture, Therapeutic Hypothermia, HEADS-ED, Pelvic Trauma, Kratom, Femoral Lines appeared first on Emergency Medicine Cases.
New Rapid Review video to refresh your memory on podcast episode 135 Commonly Missed or Mismanaged Shoulder Injuries with Arun Sayal and Dale Dantzer – Approach and Glenohumeral Dislocations. Subtle findings of posterior shoulder dislocation, shoulder x-ray considerations and nuances in shoulder dislocation reduction....
The post Glenohumeral Dislocation Rapid Review Video appeared first on Emergency Medicine Cases.
Salim Rezaie on HALT-IT trial for TXA in unstable GI bleed, Sarah Reid on pediatric DKA update in fluid management and cerebral edema, Hans Rosenberg on POCUS in shoulder dislocations via CJEM, Arun Sayal on Lisfranc injury pearls and pitfalls, Justin Morgenstern on RECOVERY Trial for Dexamethasone in COVID pneumonia, Walter Himmel on getting what you need from consultants...
The post EM Quick Hits 21 TXA in GI Bleed, Pediatric DKA, POCUS for Shoulder Dislocations, Lisfranc Injuries, Dexamethasone for COVID Pneumonia, Consultation Tips appeared first on Emergency Medicine Cases.
Justin Morgenstern on watchful waiting for large spontaneous pneumothoraces, Michelle Klaiman on mirco-dosing buprenorphine for opiate use disorder, Arun Sayal on the practical application of CRITOE in pediatric elbow fractures, Jeff Perry on The Canadian TIA Score, Sarah Reid on updated pediatric surviving sepsis guidelines, Salim Rezaie (Best of REBELEM) on safety of vasopressor administration through peripheral IVs...
The post EM Quick Hits 18 Conservative Management Pneumothorax, Microdosing Buprenorphine, Practical Use of CRITOE, Canadian TIA Score, Pediatric Surviving Sepsis Guidelines, Safety of Peripheral Vasopressors appeared first on Emergency Medicine Cases.
Dr. Arun Sayal and Dr. Dale Dantzer answer questions such as: What should be included in the list of key occult shoulder injuries that we should have in our back pockets when we are faced with a patient who has injured their shoulder and the x-ray appears normal? Which proximal humerus fractures are likely to require surgical management? Which shoulder injuries require a simple sling vs Velpeau sling vs collar and cuff vs sugar tong splint? When is an ultrasound of the shoulder indicated and how should they be interpreted? What is the best x-ray view to diagnose a sternoclavicular dislocation? What are the surgical indications for clavicle fractures? and many more...
The post Ep 136 Occult Shoulder Injuries and Proximal Humerus Fractures appeared first on Emergency Medicine Cases.
Dr. Arun Sayal and Dr. Dale Dantzer answer questions such as: How do we know we have adequate shoulder x-ray views? How can we best remember the differential diagnosis of an orthopedic extremity emergency with a normal x-ray? What is the quickest and best way to test neurologic status of patients with shoulder injuries? Why is axillary view of the shoulder so valuable? What is the biggest myth when it comes to the mechanism of injury for posterior glenohumeral shoulder dislocations? What physical exam maneuvers increase suspicion for posterior glenohumeral dislocation? What are the subtle findings on x-ray we should look for in patients with suspected posterior glenohumeral dislocation? What is the preferred first line reduction technique for posterior shoulder dislocation? What are the most common and consequential pitfalls in the management of anterior shoulder dislocations? and many more...
The post Ep 135 Commonly Missed or Mismanaged Shoulder Injuries – Approach and Glenohumeral Dislocations appeared first on Emergency Medicine Cases.
Justin Morgenstern on the lack of evidence for burn debridement, Jesse MacLaren on ECG Cases - missed ischemia and pitfalls of "normal" computer ECG interpretations, Arun Sayal on clinical diagnosis pitfalls of compartment syndrome, Sarah Reid on pediatric asthma pitfalls and myths, Andrew Petrosoniak on T-spine and L-spine fracture work-up, Michelle Klaiman & Taryn Lloyd on motivational interviewing part 2...
The post EM Quick Hits 9 Burn Blister Debridement, ECG Cases, Compartment Syndrome, Pediatric Asthma, Spinal Trauma, Motivational Interviewing P2 appeared first on Emergency Medicine Cases.
In this podcast we discuss the key concepts in assessing drug efficacy trials, and provide you with a bottom line recommendation for the use of gabapentinoids, NSAIDs and acetaminophen for low back pain and radicular symptoms, topical NSAIDs and cyclobenzaprine for sprains and strains, caffeine as an adjunct analgesic, why we should never prescribe tramadol, dexamethasone for pharyngitis, calcium channel blockers for hemorrhoids and anal fissures, buscopan for abdominal pain and renal colic and why morphine might be a better analgesic choice than hydromorphone...
The post Ep 126 EM Drugs That Work and Drugs That Don’t – Part 1: Analgesics appeared first on Emergency Medicine Cases.
This EMU 365 video features Dr. Arun Sayal on the limitations of x-rays in the assessment of orthopedic injuries in emergency medicine from North York General's Emergency Medicine Update Conference 2018...
The post EMU 365 Limitations of X-rays in Orthopedic Injuries with Arun Sayal appeared first on Emergency Medicine Cases.
In this main episode podcast we discuss the pitfalls in the diagnosis and management of elbow injuries and answer questions such as: What is an easy way to remember the surgical indications for radial head fractures? What is the significance of a coronoid process fracture and how does it change management when seen with a radial head fracture? What is the best way to assess for pronation and supination of the forearm? Why is it so important to assess for the extensor mechanism on physical exam for patients with olecranon fractures? What is a quick easy way to test the peripheral nerves of the upper extremities? Which often missed soft tissue injuries of the elbow require urgent operative management? and many more...
The post Ep 121 Elbow Injuries – Ten Pitfalls in Diagnosis and Management appeared first on Emergency Medicine Cases.
This is the 2nd instalment of The Emergency Medicine Update Conference's recently launched EMU 365 video series. In this EMU 65 video, Dr. Arun Sayal, an emergency physician who runs a weekly minor fracture clinic at NYGH discusses his approach to pediatric elbow injuries, the importance of good lateral images, common and uncommon missed elbow injuries and clinically important epicondylar fractures that can mimic normal ossification centers and more...
The post EMU 365 Pediatric Elbow Nightmares with Arun Sayal appeared first on Emergency Medicine Cases.
In this EM Cases Journal Jam podcast with Anton Helman, Justin Morgenstern, Rory Spiegel, and special guest Jacques Lee we explore the evidence for femoral nerve blocks and fascia iliaca blocks as well as discuss the practical implementation of them in your ED. We answer questions such as: Do regional nerve blocks for hip fractures effectively reduce pain? Do they decrease opioid use? Are they safe compared to standard pain management? Should the block be done prior to x-ray confirmation? and many more...
The post JJ 13 Regional Nerve Blocks for Hip Fractures appeared first on Emergency Medicine Cases.
In this month's POCUS Cases Dr. Rob Simard explains the role of POCUS in distal radius fracture diagnosis and reduction, how to troubleshoot finding the echogenic line that represents the shaft of the radius, and the limitations of using POCUS for distal radius fractures...
The post POCUS Cases 4 – Distal Radius Fracture Diagnosis and Reduction appeared first on Emergency Medicine Cases.
You probably can't remember the last time you worked a shift in the ED and didn’t see at least one patient with an ankle injury. While almost all of these patients are relatively straightforward to diagnose and manage a small but significant minority of these patients will have a more elusive diagnosis, that if not identified early, could lead to significant morbidity...
The post Ep 105 Commonly Missed Ankle Injuries appeared first on Emergency Medicine Cases.
There are a whole slew of very important occult knee injuries - those that have a normal or near normal x-ray – that can cause serious morbidity if you miss them, and for the catchall soft tissue injuries there are some subtleties in diagnosis and management that will make a real difference to our patients. Arun Sayal and Hossein Mehdian answer questions such as: When should we suspect a spontaneously reduced knee dislocation? Do all patients suspected of a spontaneous knee dislocation require a CT angiogram to rule out vascular injury? Which patients with a low energy mechanism are at risk for knee dislocation and vascular complications? How can you increase the accuracy of the active straight leg raise in assessing for quadriceps and patella tendon rupture? What is an easy way to identify patella baja and patella alta on a knee x-ray? What are the indications for ultrasound of the knee? What are the true indications for a knee immobilizer and how can knee immobilizers kill our patients? and many more...
The post Episode 91 Occult Knee Injuries Pearls and Pitfalls appeared first on Emergency Medicine Cases.
This EM Cases episode is Part 1 of The Highlights of The University of Toronto, Divisions of Emergency Medicine, Update in EM Conference from Whistler 2015 with Paul Hannam on Pearls and Pitfalls of Intraosseus Line Placement, Anil Chopra on who is at risk and how to prevent Contrast Induced Nephropathy, and Joel Yaphe on the Best of EM Literature from 2014, including reduction of TMJ dislocations, the TRISS trial (on transfusion threshold in sepsis), PEITHO study for thrombolysis in submassive PE, Co-trimoxazole and Sudden Death in Patients Receiving ACE inhibitors or ARBs, the effectiveness and safety of outpatient Tetracaine for corneal abraisons, chronic effects of shift work on cognition and much more...
The post Episode 61 Whistler’s Update in EM Conference 2015 Highlights Part 1 appeared first on Emergency Medicine Cases.
Part 2 of Hand Emergencies with Dr. Laura Tate & Dr. Andrew Arcand.
The post Episode 29b: Hand Emergencies Part 2 appeared first on Emergency Medicine Cases.
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....
The post Episode 58: Tendons and Ligaments – Commonly Missed Uncommon Orthopedic Injuries Part 2 appeared first on Emergency Medicine Cases.
We rarely discuss medico-legal issues on EM Cases because it misguides us a bit from good patient centered care – which is what emergency medicine is really all about.
Nonetheless, missed orthopedic injuries are the most common reason for an emergency doc to be sued in Canada. This is partly because missed orthopedic injuries are far more common than missed MIs for example, but it’s also because it’s easy to miss certain orthopedic injuries – especially the ones that aren’t super common. And orthopedics is difficult to learn and remember for the EM practitioner as there are so many injuries to remember.
And so, you guessed it – on this episode we’re going to run through some key not-so-common, easy to miss orthopedic injuries, some of which I, personally had to learn about the hard way, if you know what I mean.
After listening to this episode, try some cognitive forcing strategies – for every patient with a FOOSH that you see, look for and document a DRUJ injury. Wait, hold on….I don’t wanna give it all away at the top of the post.
Let’s hear what EM doc and sports medicine guru Ivy Cheng, and the orthopedic surgeon who everyone at North York General turns to when they need help with a difficult ortho case, Hossein Medhian, have to say about Commonly Missed Uncommon Orthopedic Injuries.
The post Episode 52: Commonly Missed Uncommon Orthopedic Injuries appeared first on Emergency Medicine Cases.
Dr. Sanjay Mehta & Dr. Jonathan Pirie, two experienced Pediatric EM docs from The Hospital for Sick Children in Toronto discuss their approach to a variety of common, occult, challenging and easy to miss pediatric orthopedics diagnoses including: differentiating Septic Arthritis from Transient Synovitis of the hip, Toddler's Fracture, Tillaux Fracture, Suprachondylar Fracture, ACL tear, tibial spine & Segond fractures. They also debate the value of the Ottawa Knee Rules in kids, non-accidental trauma, pediatric orthopedic pain management, the evidence for the best management of Buckle, Greenstick, Salter 1 and 2 distal radius fractures and lateral malleolus fractures.
The post Episode 35: Pediatric Orthopedics Pearls and Pitfalls appeared first on Emergency Medicine Cases.
In this episode, Dr. Jordan Chenkin & Dr. Jamie Blicker discuss positioning, landmarking, and best technique for lumbar puncture, how to minimize post-LP headache and traumatic taps, as well as when CT head is not required prior to LP. They discuss the indications, contraindications, trouble-shooting and pros and cons of needle aspiration, small bore pleural catheter with Heimlich valve and large bore chest tube for the treatment of spontaneous pneumothorax. Dr. Chenkin presents an intriguing argument for why he uses ultrasound-guided fracture reduction routinely in the ED, and we end with a few tips and tricks using skin adhesive for some unorthodox indications.
The post Episode 31: LP, Spontaneous Pneumothorax and Ultrasound Guided Fracture Reduction appeared first on Emergency Medicine Cases.
Dr. Andrew Arcand & Dr. Laura Tate discuss the key clinical pearls and pitfalls in the recognition and management of many apparently benign hand emergencies that have serious morbidity, including high pressure injection injuries, flexor tenosynovitis, gamekeeper's thumb, fight bites, hook of the hammate fractures and many more important hand emergencies.
Dr. Tate & Arcand answer such questions as: which lacerations require prophylactic antibiotics? Which hand lacerations do not require sutures? How is rotational deformity best tested for metacarpal fractures? What are the pearls of tendon repair? How do you test for instability when you suspect a Gamekeeper's thumb? How is compartment syndrome of the hand different to compartment syndrome in the leg? What are Kanavel's signs of tenosynovitis? How should felons be managed in the ED? What are the most common errors that plastic surgeons see ED docs make?
The post Episode 29: Hand Emergencies appeared first on Emergency Medicine Cases.
Dr. Laura Tate, plastic surgeon extraordinaire, presents her best hand emergency case.
In the upcoming episode, she and Dr. Andrew Arcand will discuss key pearls and pitfalls in the recognition and management of flexor tenosynovitis, high pressure injection injuries, fight bites, hook of the hammate fractures, gamekeeper's thumb and many more potentially devastating hand emergencies.
The post Best Case Ever 14: High Pressure Injection Injury appeared first on Emergency Medicine Cases.
In this episode we go through seven cases that display the breadth of presentations of limb or life threatening causes of low back pain emergencies with my huge mentors, Dr. Walter Himmel and Dr. Brian Steinhart. We cover everything from spinal epidural abscess to cauda equina syndrome to retroperitoneal bleeds, elucidating the key historical, physical exam, lab, imaging and treatment pearls for all of these diagnoses. We then go on to review the best management for the most common cause of back pain presentation, lumbosacral strain and debate the various medication options.
The post Episode 26: Low Back Pain Emergencies appeared first on Emergency Medicine Cases.
Ep16 MonoarthritisDr. Joel Yaphe, University of Toronto's Emergency Medicine Residency Program Director and Dr. Indy Ghosh discuss the difficult diagnostic dilemmas when faced with a patient with acute monoarthritis. They review how to distinguish clinically between septic arthritis and gout and which aspects of the presentation and work-up are the most reliable in risk stratifying patients. The key differential diagnosis of Acute Polyarthritis can be even more of a challenge, but fear not: by then end of this podcast and post you will be able to recognize the key diagnoses, how to work them up, and who needs consultation.
The post Episode 16: Acute Monoarthritis appeared first on Emergency Medicine Cases.
Septic Arthritis is often at the top of our differential for acute monoarthritis. Dr. Joel Yaphe tells his Best Case Ever of a patient with septic arthritis as a bonus to Episode 16: Acute Monoarthritis.
In the related episode Dr. Yaphe and Dr. Indy Ghosh discuss such questions as: What are the most important risk factors for septic arthritis? What are the most predictive signs and symptoms of septic arthritis? How does serum WBC, ESR and CRP contribute to the probability of septic arthritis? Should we still be performing arthrocenteses on patient's with overlying cellulitis? with an INR of 6? How can you tell the difference between septic bursitis and septic arthritis and how are they managed differently? What does the literature tell us about how useful the synovial fluid tests are in ruling in or ruling out septic arthritis? What is the role of bedside ultrasound in septic arthritis? Is there a role for steroid therapy in septic arthritis? When would you consider oral NSAIDs vs oral prednisone vs intra-articular methylprednisolone for the treatment of Gout? Is there a role for colchicine in the ED treatment of Gout? What is acute calcific arthritis of hydroxyapatite disease and why is it important for ED docs to know about? What is the most common cause of dermatitis-arthritis? How can one distinguish Reactive Arthritis from Septic Arthritis clinically, and how do their work-ups differ? Is there a role for antibiotics in Reactive Arthritis? How does gonococcal arthritis present compared with nongonococcal septic arthritis? and many more.....
The post Best Case Ever 5 Septic Arthritis appeared first on Emergency Medicine Cases.
Dr. Arun Sayal and Dr. Natalie Mamen discuss the key diagnostic considerations in commonly missed occult fractures and dislocations. They review the indications and controversies for the use of Bone Scan, CT and MRI in occult fractures and dislocations and give you some great clinical pearls to use on your next shift.
Missed occult fractures and dislocations, in general, may result in significant morbidity for the patient and law suites for you. Six cases are presented in this episode, ranging from common scaphoid fractures to rarer dislocations. Dr. Sayal & Dr. Mamen answer questions such as: Which fractures can mimic ankle sprains and how do you avoid missing them? What are the most reliable signs of scaphoid fracture? In which occult orthopaedic injuries should we anticipate limb threatening ischemia? Which is better to diagnose occult fractures - MRI or CT? Which calcaneus fractures require surgery and which ones can be managed conservatively? and many more......
The post Episode 1: Occult Fractures and Dislocations appeared first on Emergency Medicine Cases.