Answer: Fracture of the intercondylar eminence of the tibia; Meyers & McKeever Grade II (grading system described below)

Intercondylar Eminence Fracture

• Avulsion of the insertion of the ACL because the ligament stronger than incompletely ossified bone in children
• Incidence is 3 in 100,000 children
• Most common injury mechanism
  • Falls from a bicycle
  • Motor vehicle crash
• Meyers and McKeever’s classification system
  • I (non-displaced) - Generally treated non-operatively with long-leg casting
  • II (hinged fragment)  - Generally treated like Grade I
  • III (displaced) - Requires surgical fixation

Reference: Tudisco, C., et al Intercondylar eminence avulsion fracture in children: long-term follow-up of 14 cases at the end of skeletal growth, J Pediatr Orthop B 19:403–408 c 2010

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Answer #1: Multifocal opacities predominantly in left lower lobe representing pneumonia 

Answer #2 Healing left-sided rib fractures involving the lateral aspects of ribs 8 through 10^th suspicious for non-accidental trauma (see X-ray below)

Pediatric CXR pearls

• Always remember to thoroughly examine x-rays to screen for abnormal findings.
• Posterior rib fractures are highly suspicious for abuse in pediatric patients as the differential is very small beyond accidental trauma.
• General risk factors increasing the risk for pediatric rib fractures:
  • Gestational age less than 30 weeks
  • Low-birth weight
  • Chronic lung disease
  • Chronic diuretic use
  • Prolonged parenteral nutrition

Bottom line: Screen patients for the above risk factors when rib fractures have been identified, but always think of abuse and the child’s safety first….and don’t forget to thoroughly examine radiology despite finding one abnormal finding.

Reference: Cosway et al.  Diagnostic indicators for NAI in children with rib fractures: A retrospective study.  Arch Dis Child 2011; 96 (supplement)

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Answer: Posterior shoulder dislocation

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Answer: Salter-Harris Fracture - Type II 

Salter-Harris Fracture (SHF)

SHF are fractures through the growth plate (a.k.a. the physis), therefore are unique to pediatric patients.

Fractures are categorized according to involvement of the physis, metaphysis, and epiphysis. Proper injury classification is important because it affects both the treatment and potential long-term complications. Radiographic findings can sometimes be subtle; especially Type 1 SHF.

Occult SHF should be suspected when there is tenderness or swelling over an epiphyseal surface with X-rays negative for fracture. In this case, children should be splinted and urgently followed up.

SHF classification

• Type I: Disruption along growth plate (or physis) without bony fracture; may be occult 
• Type II (most common): Separation through growth plate and fracture through metaphysis
• Type III:  Intra-articular fracture of epiphysis into growth plate 
• Type IV: Intra-articular fracture of epiphysis through entire growth plate and metaphysis
• Type V: Crush injury of growth plate

Bonus Pearl:

Use mnemonic SALTR to remember fracture type (Type I-Slipped, II-Above physis, III-Lower physis, IV-Through physis, V-Rammed)

emedicine.medscape.com/article/412956-overview

Salter, R and Harris R.  Injuries involving the Epiphyseal Plate. Journal of Bone and Joint Surgery.  Vol 45-A. Issue 3, April 1963.

fpnotebook.com/_media/OrthoFractureSalterHarris.jpg

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Answer: Click here or here

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Answer: Inverted left hemidiaphragm (or deep sulcus sign) secondary to a tension pneumothorax. There is also a superimposed hemothorax.

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Answer: Pulmonary contusion 

Blunt chest trauma may result in pulmonary contusion, a parenchymal lung injury resulting in blood and edema within the alveolar spaces.

The pathophysiologic effects result in reduced lung compliance and gas exchange (i.e., dead space ventilation and/or shunting), increased risk of ARDS, and increased pulmonary vascular resistance. The full pathophysiologic effects may take up to 48 hours to develop. Resolution usually occurs within 3-5 days.

Diagnosis is typically made on CXR, although early CXR may underestimate the severity of injury. CT scan is much more sensitive for diagnosis (see green arrows below).

Management is supportive and requires strict attention to oxygenation. Positive pressure ventilation is occasionally required for respiratory failure and is sometimes recommended prophylactically for elderly patients, because their pulmonary status can rapidly decline secondary to their reduced lung reserve.

Aggressive control of chest wall pain is also required. Pain reduces both the frequency and depth of respirations leading to atelectasis, a reduction in mucus clearance, and an increased risk of pneumonia. Analgesia should be administered systemically, by epidural, or by local nerve block at the level of injury.

Lively, M. Pulmonary contusion in a collegiate diver: a case report. J Med Case Rep. 2011 Aug 10;5:362.

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Answer: Mebendazole or albendazole 

The image above shows an Ascaris Lumbricoides (AL), the most common intestinal roundworm infection in humans. It typically occurs in inhabitants of impoverished areas with poor sanitation. 

Humans acquire AL from ingesting eggs from infected food or soil. Eggs hatch into larvae within the small intestine and then migrate through the mucosa to vascular beds of the alveoli within the lung. Larvae then migrate up the respiratory tree and are swallowed into the GI tract where they mate and more eggs are laid, maturing here or migrating to other organs within the body. 

Most infections are asymptomatic, but signs and symptoms can range from nonspecific pulmonary (first two weeks secondary to larval migration into lungs) to severe (after six weeks secondary to the mechanical effects of high parasite load in the gut). Symptoms include: 

• Dyspnea, cough, wheezing, fever, etc. (migration of larvae through the lungs)
• Malnourishment, iron-deficiency anemia, weight loss, GI obstruction, etc. (mechanical effects of a large parasite load)

Treatment during early infection is challenging because AL is non-specific and difficult to diagnose; symptomatic and supportive care is required. When the diagnosis is made, medications such as mebendazole and albendazole can be used to eradicate AL directly within the gut. Situations where worms cause intestinal obstruction, require manual debulking using scopes (e.g., colonoscopy) or surgery.

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Answer: Herpes zoster ophthalmicus

Herpes Zoster Ophthalmicus

• Zoster involving the ophthalmic branch (V1) of the trigeminal nerve
• Concomitant nasal rash is called Hutchinson's sign and heralds involvement of the eye (specifically the cornea); the nasociliary nerve innervates both the nose and eye
• Must perform a thorough evaluation of the eye including slit lamp and fluorescein
• Consider admission if:
  • symptoms are severe 
  • 2 or more dermatomes are involved
  • patients are immunocomprosmised
• ​Treatment is with ​acyclovir, valacyclovir, or famciclovir

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Answer: The most common anatomic sites for intra-cerebral hemorrhage are:

1. Basal ganglia (40-50%)
2. Intralobar (20-50%)
3. Thalamus (10-15%)
4. Pons (5-12%)
5. Cerebellum (5-10%), 

...and, don't forget the most common causes of non-traumatic intra-cerebral hemorrhage: 

• Systemic hypertension (essential, drug use, ecclampsia)
• Rupture of arteriovenous malformation or aneurysm 
• Arterial disease (e.g., cerebral amyloid angiopathy)
• Congenital or acquired coagulopathy
• CNS tumor with necrosis and hemorrhagic conversion

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Answer: Staghorn caliculi secondary to struvite stone. Broad-spectrum antibiotics to cover anaerobic bacteria should be initiated.

• Staghorn caliculi are upper urinary stones involving both the renal pelvis and at least 2 calyces.
• Any category of renal stone can form a staghorn calculi, but most are magnesium-ammonium-phosphate stones (i.e., struvite stones); struvite stones are typically associated with urinary tract infections secondary to urease-producing bacteria (e.g., Proteus species).
• Struvite stones may result in several types of urinary tract infections; perinephric abscess, pyelonephritis, and in severe cases, sepsis.
• Management includes:
  • Early broad-spectrum antibiotics covering both aerobic and anaerobic bacteria until culture and sensitivities are available
  • Complete removal of stone is necessary (e.g., extracorporeal-shockwave lithotripsy, surgery, etc.)
• The CT shown here demonstrates a left kidney struvite stone with associated air (green arrows) suggesting an anaerobic infection.

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Answer: Type A Dissection

Click here for an explanation. 

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Answer: Anterior knee-dislocation and Ankle-Brachial Index (ABI) 

Both anterior and posterior knee-dislocations have the potential for popliteal arterial injury. 

ABI compares Doppler pressures of arms to legs to screen for lower limb ischemia (click here to learn more ABIs). ABIs can be used to accurately predict whether patients with knee dislocations have sustained vascular injury. 

A prospective study by Mills et al. demonstrated the sensitivity, specificity, and positive predictive values of an ABI lower than 0.90 were 100% for arterial injury, requiring surgical treatment.

Conversely, the negative predictive value of an ABI that was 0.90 or higher was 100%, suggesting no further workup is required.

Mills W, Barei D, McNair P. The Value of the Ankle-Brachial Index for Diagnosing Arterial Injury After Knee Dislocation: A Prospective Study.  Journal of Trauma-Injury Infection & Critical Care: June 2004 - Volume 56 - Issue 6 - pp 1261-1265.

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Fragou, M. et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med. 2011 Jul;39(7):1607-12.

Answer: Mandibular dislocation...and the Gromis method? 

•    The Gromis method (a.k.a. the "Masseteric Massage" technique) is an alternative method for reducing mandibular dislocations.

•    Firm, direct, and constant pressure is applied bilaterally to the masseter muscles, which relaxes the muscles (i.e., reduces spasm) and allows mandibular reduction with less traction than traditional reduction techniques and with no procedural sedation. 

•    Rob Orman (@emergencypdx) posts a video of Dr. Daniel Gromis demonstrating the technique: http://vimeo.com/46453741

•    Finally, UMEM pearl regulars may recognize this Xray from a post last year where we described another alternative method to reduce mandibular dislocations. Here it is again: http://www.youtube.com/watch?v=Kp8AzHIC0hM

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Answer: Aortic dissection / transection

Blunt Aortic Injury

• Occurs in < 1% of MVCs; causes 16% of blunt trauma deaths overall.
• 80% die before reaching hospital; 30% who survive to hospital will die if missed.
• Ligamentum arteriosum is the most common site of injury
• CXR: widened mediastinum (suggestive);  CT angiography is diagnostic (CT with 3D reconstruction below; arrow below indicates defect).
• Treatment: Beta-blocker infusion (e.g., esmolol) +/- vasodilator to keep the heart rate <60 BPM and systolic blood pressure 120 mmHg; both temporizing measures until surgical correction can be performed 
• Debate whether open aortic repair or TEVAR (Thoracic EndoVascular Aortic Repair) results in the best outcomes.  

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