Tongue-type calcaneus fractures: a threat to skin.

Calcaneal fractures account for 60% of all tarsal bone fractures. Tongue-type calcaneus fractures are longitudinal fractures that exit the calcaneal tuberosity posteriorly and involve a portion of the articular surface. They are often superiorly displaced because of the insertion of the Achilles tendon and pull of the gastroc-soleus complex. Skin compromise complicates a large percentage of these injuries because of the thin layer of soft tissue and superficial nature of the fracture. Early recognition by the emergency physician and prompt operative repair prevent further injury and obviate the need for surgical soft tissue coverage or potential amputation.

Capitellum fracture: detecting fat pads may have a significant impact on outcome.

Capitellum fractures account for less than 1% of all elbow fractures. Their appearance on plain radiographs may be subtle. It is this combination of features that make these injuries easy to misdiagnose. Misdiagnosis of a nondisplaced capitellum fracture is significant because the capitellum does not have soft tissue attachments and can convert to a displaced fracture that will need surgery. Although a prior study has reported a high incidence of occult elbow fractures when elevated fat pads are present, it did not demonstrate an impact on management. Our case illustrates that because of the capitellum's propensity to displace, detecting fat pads and immobilizing the elbow may have a significant impact on outcome.

Posterior displacement of a proximal epiphyseal clavicle fracture.

Posterior clavicle dislocations are uncommon injuries but are associated with serious complications based on their proximity to mediastinal structures. In children, the physis is the weakest point structurally, making a displaced Salter I fracture more common than a true sternoclavicular joint dislocation. This injury may be missed on exam and routine radiographs unless a high suspicion is maintained. A CT scan with contrast may be helpful for diagnosis of this injury and detection of complications to mediastinal structures. Emergent reduction is required in cases where there is vascular compromise.

Pneumobilia: benign or life-threatening.

Pneumobilia, or air within the biliary tree of the liver, suggests an abnormal communication between the biliary tract and the intestines, or infection by gas-forming bacteria. Pneumobilia usually can be distinguished from air in the portal venous system by its appearance on computed tomography (CT) scan. The most common conditions associated with pneumobilia include: 1) a biliary-enteric surgical anastamosis, 2) an incompetent sphincter of Oddi, or 3) a spontaneous biliary-enteric fistula. Three cases of pneumobilia associated with its most common causes are presented and further differential diagnostic possibilities as well as the implications of this finding on patient management are discussed.

Pontine hemorrhage presenting as an isolated facial nerve palsy.

We report a case of an isolated facial nerve palsy in a young, otherwise healthy man who was found to have a pontine hemorrhage on computed tomography. Pontine hemorrhage is a rare cause of facial nerve palsy and has been reported in the literature as an isolated neurologic finding in only 1 other instance. This case reminds the emergency physician to remain vigilant for alternative causes of facial nerve palsy other than "idiopathic" Bell's palsy.

Aortic dissection in a young man with immune thrombocytopenic purpura.

A 36-year-old man who presented with epigastric and back pain was subsequently diagnosed with aortic dissection. Our patient lacked classic risk factors that would have predisposed him to develop this condition at a young age. He did, however, suffer from untreated, chronic immune thrombocytopenic purpura (ITP) and had a platelet count less than 20,000/mm(3) on admission. We postulate that the thrombocytopenia led to spontaneous hemorrhage within the vasa vasorum of the aorta and the subsequent development of aortic dissection. Chronic ITP has been associated with an increased risk of intracranial hemorrhage but, to our knowledge, has not been reported to be associated with aortic dissection. We encourage clinicians to be aware of this potential risk factor for aortic dissection.

Reexpansion pulmonary edema: a case report and review of the current literature.

This case report illustrates the presentation and course of reexpansion pulmonary edema (REPE) in a young man with spontaneous pneumothorax. REPE is considered relatively uncommon by most accounts, but in certain clinical circumstances the incidence is much higher. Although supportive therapy is the rule, the condition is far from benign and mortality estimates are as high as 20%. Risk factors, including young age, a large pneumothorax and longer duration of collapse, may help predict which patient will encounter this complication. In patients with these risk factors, the thoracostomy tube should be initially left off suction in an effort to prevent REPE primarily. When REPE is encountered, therapy is supportive.

Gradenigo syndrome: a case report and review of a rare complication of otitis media.

Otitis media is a commonly seen condition in the Emergency Department. The complications of otitis media that were seen frequently in the preantibiotic era are now rare today. We report a case of a diabetic man who presented with otorrhea, retro-orbital pain, and diplopia secondary to a sixth cranial nerve palsy--Gradenigo syndrome. This syndrome occurs as infection from the middle ear spreads medially to the petrous portion of the temporal bone. The emergency physician should consider this condition in patients with chronic ear drainage or pain not responsive to conventional treatment or in any patient with a cranial nerve palsy in the setting of acute or chronic otitis. Work-up should include a CT scan of the temporal bones. Otolaryngology consultation and admission for i.v. antibiotics is recommended.

Acute myocardial infarction in a young man with sickle cell disease.

Sickle cell disease is considered protective against large vessel coronary artery disease. Although sickle cell patients do develop myocardial degeneration and fibrosis at a higher rate than age-matched controls, they rarely suffer from an acute myocardial infarction. We present a case of a 29-year-old man with sickle cell disease who presented with an acute non-ST segment myocardial infarction. In sickle cell patients who present with chest pain as an element of their sickle cell crisis, the clinician must consider acute myocardial infarction in the differential along with more common entities like acute chest syndrome.