Portable dynamic ultrasonography is a useful tool for the evaluation of suspected syndesmotic instability: a cadaveric study.

PURPOSE: Portable ultrasonography (P-US) is increasingly used to diagnose syndesmotic instability. The aim of this study was to evaluate syndesmotic instability by measuring the distal tibiofibular clear space (TFCS) in a cadaveric model using P-US with progressive stages of syndesmotic ligamentous transection under external rotation stress. METHODS: Ten fresh lower leg cadaveric specimens amputated above the proximal tibiofibular joint were used. Using P-US, the TFCS was evaluated in the intact stage and after progressive sectioning of the (1) anterior-inferior tibiofibular ligament (AITFL), (2) interosseous ligament (IOL), and (3) posterior-inferior tibiofibular ligament (PITFL). The TFCS was measured in both the unstressed (0 Nm) state and with 4.5, 6.0, 7.5, and 9.0 Nm of external rotation stress using a bone hook placed on the first metatarsal bone at each stage of ligamentous transection stage using both P-US and fluoroscopy. RESULTS: When assessed with P-US, partial syndesmotic injury encompassing the AITFL and IOL resulted in significant TFCS widening at 4.5 Nm of external rotation torque when compared to intact state with a TFCS-opening of 2.6 ± 2 mm, p = 0.01. In contrast, no significant differences in TFCS were detected using fluoroscopy. Only a moderate correlation was found between P-US and fluoroscopy. CONCLUSION: P-US is a useful tool in diagnosing syndesmotic instability during external rotation stress examination. TFCS-opening increased as additional ligaments of the syndesmosis were transected, and application of 4.5 Nm torque was sufficient to detect a difference of 2.6 mm after the IOL cut.

Worldwide epidemiology of foot and ankle injuries during military training: a systematic review.

INTRODUCTION: Musculoskeletal foot and ankle injuries are commonly experienced by soldiers during military training. We performed a systematic review to assess epidemiological patterns of foot and ankle injuries occurring during military training. METHODS: A review of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search, done on 14 February 2019, resulted in 1603 reports on PubMed, 565 on Embase and 3 on the Cochrane Library. After reading the remaining full-text articles, we included 91 studies. RESULTS: Among a population of 8 092 281 soldiers from 15 countries, 788 469 (9.74%) foot and ankle injuries were recorded. Among the 49 studies that reported on length of training, there were 36 770/295 040 (18.17%) injuries recorded among women and 248 660/1 501 672 (16.56%) injuries recorded among men over a pooled mean (±SD) training period of 4.51±2.34 months. Ankle injuries were roughly 7 times more common than foot injuries, and acute injuries were roughly 24 times more common than non-acute injuries. Our findings indicated that, during a 3-month training period, soldiers have a 3.14% chance of sustaining a foot and ankle injury. The incidence of foot or ankle injury during military parachutist training was 3.1 injuries per thousand jumps. CONCLUSIONS: Our findings provide an overview of epidemiological patterns of foot and ankle injuries during military training. These data can be used to compare incidence rates of foot and ankle injuries due to acute or non-acute mechanisms during training. Cost-effective methods of preventing acute ankle injuries and non-acute foot injuries are needed to address this problem.

Optimizing surgery of metaphyseal-diaphyseal fractures of the fifth metatarsal: a cadaveric study on implications of intramedullary screw position, screw parameters and surrounding anatomic structures.

AIMS: Many advocate screw fixation of fractures to the metaphyseal-diaphyseal junction of the fifth metatarsal base, better known as Jones fractures (JF), to facilitate quicker ambulation and return to sport. Maximizing screw parameters based on fifth metatarsal (MT5) anatomy, alongside understanding the anatomic structures compromised by screw insertion, may optimize surgical outcomes. This study aims to (1) correlate the proximity of JF to the peroneus brevis (PB) and plantar fascia (PF) footprints and (2) quantify optimal screw parameters given MT5 anatomy. MATERIALS AND METHODS: 3D CT-scan reconstructions were made of 21 cadaveric MT5s, followed by meticulous mapping of the PB and PF onto the reconstructions. Based on bone length, shape, narrowest intramedullary canal (IMC) diameter, and surrounding anatomy, two traditional debated screw positions were modeled for each reconstruction: (1) an anatomically positioned screw (AP), predicated on maximizing screw length by following the IMC for as long as possible, and (2) a clinically achievable screw (CA), predicated on maximizing screw length without violating the fifth tarso-metatarsal joint or adjacent cuboid bone. Fixation parameters were calculated for all models. RESULTS: The PB and PF extended into the JF site in 29% and 43%, respectively. AP's did not affect PB and PF footprint but required screw entry through the cuboid and fifth tarso-metatarsal joint in all specimens. CA screw entry sites, avoiding the cuboid and fifth tarso-metatarsal joint, partially compromised the PB and PF insertions in 33% and 62% with a median surface loss of 1.6%%(range 0.2-3.2%) and 0.81%%(range 0.05-1.6%), respectively. Mean AP screw length was 64±3.6mm and thread length 49±4.2mm. Mean CA screw length was 48±5.8mm and thread length 28±6.9mm. CONCLUSION: This study underscores the challenges associated with surrounding MT5 anatomy as they relate to optimal JF treatment. Both the extent of JF as well as a clinically achievable positioned screw violate the PB and PF footprints - although the degree to which even partial disruption of these footprints has on outcome remains unclear. To minimize damage to surrounding structures, including the PB and PF footprint, while allowing a screw length approximately two thirds of the metatarsal length, the CA screw position is recommended. This position balances the desire to maximize pull out strength while avoiding cortical penetration or inadvertent fracture site distraction.

Diagnosing syndesmotic instability with dynamic ultrasound - establishing the natural variations in normal motion.

BACKGROUND: Syndesmotic instability, when subtle, is challenging to diagnose and often requires visualization of the syndesmosis during applied stress. The primary aim was to assess normal distal tibiofibular motion in the sagittal plane using dynamic ultrasound under stress conditions. The secondary aim was to evaluate the reliability of dynamic stress ultrasonography. METHODS: Twenty-eight participants without history of ankle injury were included. Sagittal fibular translation was generated by applying a manual force to the fibula from anterior to posterior and from posterior to anterior. Distance between the ultrasound probe and the fibula was taken at two predefined points: 1) no force applied and, 2) during maximum force application. Each participant was scanned twice by two independent examiners, and each scan was analysed by two independent examiners. Three participants were scanned a second time by the same examiner who analysed these films twice to assess for intraobserver agreement. Means of exam 1 versus exam 2 were compared using a mixed linear model. Agreement among observers was calculated using intraclass correlation coefficients (ICC) interpreted as 0.4, poor; 0.4 〈 ICC < 0.59, acceptable; 0.6 < ICC < 0.74, good; ICC 〉 0.74, excellent. RESULTS: Fifty-six ankles were included in the study, including 16 (57%) males and 12 (42%) females. Average anterior to posterior fibular sagittal translation was 0.89 ± 0.6 mm and posterior to anterior fibular sagittal translation was 0.49 ± 1.1 mm. Anterior to posterior translation means of exam 1 versus exam 2 showed no significant differences, means of 0.81 mm [0.7-0.9] versus 0.77 mm [0.7-1.0], and posterior to anterior means [95% CI] of 0.42 mm [0.3-0.5] versus 0.44 mm [0.2-0.6] (p-values 0.416 and 0.758, respectively). Excellent Inter- and intraobserver agreement was found for all measurements taken. CONCLUSION: Dynamic ultrasound allows one to effectively and readily evaluate sagittal translation of the distal tibiofibular joint. It is able to afford bilateral comparisons, which becomes critical as the amount of syndesmotic instability approaches greater degrees of subtlety.

Comparison of men and women presenting to an ED with acute appendicitis.

Appendicitis is a common problem presenting to the Emergency Department (ED). Missed or delayed diagnosis can result in increased morbidity and is a common cause of malpractice claims. Diagnosis in women is more difficult because of additional clinical considerations. The study hypothesis is that women with appendicitis presenting to an ED experience a longer delay to operative intervention resulting in an increased rate of perforated appendix. A retrospective chart review of 196 male and female patients between twelve and fifty years of age presenting to the ED with final discharge diagnosis of appendicitis was performed. Mean time from ED presentation to operative intervention was 477 minutes for men and 709 minutes for women (P = .02). Perforated appendix was present in 38.7% of men and 23.5% of women (P = .002). Women with appendicitis presenting to an ED experience significant delay to surgery, however, this is not associated with an increased rate of perforation.

Use of a complete neurological examination to screen for significant intracranial abnormalities in minor head injury.

Indications for head computed tomography (CT) scans are unclear in patients with nonpenetrating head injury and Glasgow Coma Scale (GCS) scores of 15. We performed a prospective study to determine if significant intracranial injury could be excluded in patients with GCS-15 and a normal complete neurological examination. A prospective trial of clinically sober adult patients with GCS = 15 on emergency department (ED) presentation after closed head injury with loss of consciousness or amnesia was conducted from May 1996 through April 1997. All subjects underwent a standardized neurological examination including mental status evaluation, and assessment of motor, sensory, cerebellar and reflex function before CT scan. During the study period, 58 patients met inclusion criteria. Fifty-five patients (95%) had normal CT scans and 23 (42%) had focal neurological abnormalities. Three patients (5%) had CT scan findings of acute intracranial injury, two of whom had normal neurological examinations. One patient had an acute subdural hematoma requiring emergent surgical decompression; the other had both an epidural hematoma and pneumocephalus that did not require surgery. Significant brain injury and need for CT scanning cannot be excluded in patients with minor head injury despite a GCS = 15 and normal complete neurological examination on presentation.

Pantomography vs mandibular series for the detection of mandibular fractures.

OBJECTIVE: The two primary radiographic techniques used for the evaluation of mandible injury are a pantomographic series (PS) and the standard four-view mandibular series (MS). Despite a tenuous foundation, there is apparent bias in favor of PS compared with MS. Many emergency departments do not have ready access to the specialized equipment necessary to perform a pantomographic study. The hypothesis of this study was that a high-quality standard MS is as sensitive and specific as a PS in the detection of mandibular fractures. METHODS: This was a prospective, blinded study of 54 patients presenting with acute mandibular injury comparing MS and PS. The study design used two board-certified emergency physicians and a single staff radiologist who read a series of MS and PS films in a randomized fashion without access to clinical information or identifying patient data. The absolute number of fractures present was determined by a neuroradiologist with access to both MS and PS simultaneously as well as pertinent clinical information. RESULTS: Thirty patients had 47 mandibular fractures. The sensitivity for fracture detection for each physician was 0.85, 0.77, and 0.89 with MS and 0.79, 0.74, and 0.83 with PS (p > or = 0.51, p > or = 1.00, and p > or = 0.51, respectively, McNemar's binomial test). The specificity for fracture detection for each physician was 0.88, 0.92, and 0.96 for MS and 0.96, 1.00, and 0.92 for PS (p > 0.625, p > 0.50, and p = 1.00, respectively, McNemar's binomial test). CONCLUSIONS: A standard mandibular series is as sensitive and specific as pantomography in the detection of mandibular fractures.

Emergency department airway management before and after an emergency medicine residency.

To determine whether the start of an Emergency Medicine (EM) training program affects the appropriateness, timeliness, and safety of Emergency Department (ED) intubations, all ED intubations performed 12 months before and after the start of an EM residency were reviewed. In addition, all patients intubated within 12 h after being admitted through the ED were reviewed. We found that all ED intubations before and after the start of a residency program were deemed appropriate. Of patients intubated after admission, 13 of 20 (65%) were felt to have warranted intubation while in the ED for the pre-residency group, compared with 9 of 29 patients (31%) for the post-residency group. There were no differences between the complication rates of these groups. We conclude that an EM residency program did not increase the number of inappropriate intubations or complications, and reduced the number of patients who required but did not receive intubation in the ED.

Emergency department management of occupational exposures to HIV-infected fluids.

The emergency department is where many healthcare workers will seek medical advice and care after a potential exposure to bodily fluids contaminated with the human immunodeficiency virus (HIV). The estimated risk of HIV infection in healthcare workers with percutaneous exposures to HIV-infected blood is estimated at 0.3% to 0.32%. Zidovudine (AZT) post-exposure prophylaxis has been associated with a 79% reduction in the risk of seroconversion in a case-control study sponsored by the Center for Disease Control and Prevention (CDC), and has become part of the standard prophylactic treatment for patients with occupational HIV exposure. This article reviews the current CDC recommendations as well as our institutional practice guidelines for the management of healthcare workers who are exposed to potential or confirmed HIV-infected fluids.

Central nervous system tuberculoma: a case report.

Pediatric cerebral tuberculoma is a disease rarely encountered in the United States. We report a case of central nervous system tuberculoma in a 6-month-old infant who presented to the emergency department with isolated right upper extremity paralysis. The discussion includes a brief review of central nervous system tuberculomas.

Influence of insurance coverage on delays in seeking emergency care in patients with acute chest pain.

The time required to decide to seek medical care for acute chest pain is the major modifiable component in the process of care delivery. This study demonstrates that prehospital delay in the setting of acute chest pain was related to the type of health insurance.

Scombroid fish poisoning: successful treatment with cimetidine.

Reported is a patient with a clinical syndrome characteristic of scombroid fish poisoning after ingesting yellowfin tuna that may have been allowed to sit at room temperature for some time before preparation. The patient was treated with an intravenous infusion of cimetidine with prompt resolution of a diffuse, well demarcated, erythematous, pruritic rash. The treatment was without sequelae and permitted early discharge from the emergency department. A brief review of scombroid fish poisoning and its treatment is provided.

Hip fracture presenting as isolated knee pain.

Hip fracture is commonly seen in the emergency department. Clinical presentation generally includes a history of trauma or fall, a complaint of pain in or around the hip, and physical findings of limb shortening or external rotation. A case of spontaneous hip fracture in an elderly woman presenting as pain isolated to the anterior knee alone is reviewed. Recognition of this atypical presentation will aid prompt diagnosis of this common clinical entity.

Actinobacillus ureae meningitis: case report and review of the literature.

Actinobacillus urea, formerly known as Pasteurella ureae, is an uncommon commensal of the upper respiratory tract in humans. It has been identified as the primary pathogen in 10 cases of meningitis and several cases of pneumonia, sepsis, and peritonitis. A case is presented that represents another documented case of meningitis due to this rare organism. Risk factors associated with serious infection due to Actinobacillus ureae and basic management approaches to posttraumatic meningitis in general are discussed.

The management of sharps in the emergency department: is it safe?

In this study, we observed the management of sharps by health care workers including physicians, nurses, technicians, and students in the Emergency Department of the University of California-San Diego Medical Center. Twenty-eight percent of 418 observed sharp utilizations were managed in such a way that excess risk was conferred to the user, another person, or both. Twenty-seven percent conferred excess risk to the user and 12% to another person. Twenty percent of 322 recappable needles were recapped using a two-handed technique; 64% were disposed of uncapped. Four sharps (1%) were inadvertently thrown in the trash. Of the 418 observed sharp utilizations, none resulted in a puncture wound, although the four that were thrown in the trash represent a very high risk of injury to others. Physicians were observed handling the highest percentage of sharps in manners associated with excess risk while technicians and students managed sharps with the least risk. Among sharps used on patients who were IV drug abusers with unknown HIV status, 29% (n = 28) were handled with excess risk to the user, another person, or both. Of 24 sharps used on known HIV-infected patients, there were no practices observed that subjected either the user or another person to excess risk.

The acquired immune deficiency syndrome: an overview for the emergency physician, Part 2.

Human immunodeficiency virus (HIV) affects all organ systems. Infection of the heart can manifest with evidence of myocarditis, pericarditis, or cardiomyopathy. The most common gastrointestinal symptom is diarrhea, which can result from infection with a variety of bacterial, fungal, or protozoal organisms. In about 15% of cases, no pathogen is recognized and the diarrhea syndrome is termed AIDS enteropathy. Any portion of the alimentary tract can be affected as well as the liver, gallbladder, and pancreas. Cryptosporidium, a previously infrequent cause of human illness, has emerged as an important pathogen in the HIV-infected patient and is responsible for chronic diarrhea, cholecystitis, and biliary tract obstruction. Evidence of neurologic involvement is present in more than 80% of patients at the time of autopsy. Cryptococcal meningitis, toxoplasma encephalitis, and neurosyphilis are the most often encountered central nervous system infections. While all three are responsive to therapy, treatment must be prolonged or persist for the duration of the patient's life to avoid recurrence. Peripheral nervous system manifestations include myelopathy, myopathy, and a variety of peripheral neuropathies. Retinal infection with cytomegalovirus (CMV) and toxoplasma can lead to irreversible loss of vision. Cotton wool spots are a common benign physical finding that must be differentiated from the early signs of CMV or toxoplasma infection. Management of the HIV-infected patient, while most often conducted by specialists in Internal Medicine or Infectious Diseases, is often an issue for the emergency physician. Many of the commonly afforded therapies are reviewed. Part 1 of this two-part series discussed the pathophysiology and clinical expression, epidemiology, laboratory testing, and the general clinical manifestations of AIDS, as well as dermatologic, pulmonary, and cardiac symptoms. Part 2 discusses the gastrointestinal, neurologic, and ocular symptoms, as well as the treatment and management of the AIDS patient.

The acquired immune deficiency syndrome: an overview for the emergency physician, Part 1.

The acquired immune deficiency syndrome (AIDS) was recognized as a distinct entity in 1981. It began as a medical curiosity affecting only several dozen individuals in a restricted segment of the U.S. population. In the 12 years since its description, AIDS has become a pandemic affecting tens of millions with cases reported from all major countries. The illness is caused by a retrovirus, termed human immunodeficiency virus (HIV). It is a blood-borne disease with sexual, parenteral, and perinatal modes of transmission. Infection with the virus can be determined by a number of serologic techniques as well as viral culture. The pathophysiology of illness is incompletely understood, but is in large part related to destruction of helper, CD4 lymphocytes. This results in immune dysfunction and the development of a variety of opportunistic infections and malignancies. A great deal has been learned over the last decade, with important advances in treatment. Zidovudine (AZT) remains the most important agent in slowing progression of the disease and has resulted in prolonging survival. All organ systems can be affected by HIV, and many clinical manifestations are protein. Fever, weight loss, and diarrhea are often encountered general symptoms. The skin is frequently involved, with Kaposi's Sarcoma the most common malignancy and a variety of fungi and viruses the most frequent cause of infection. The lung is involved in the majority of patients, with Pneumocystis Carinii (PCP) and mycobacteria emerging as the most important pathogens. A variety of treatments have demonstrated efficacy for PCP. The risk of PCP is related to the decay in CD4 lymphocytes so that prophylactic treatment is recommended when CD4 counts fall below 200. Mycobacterial infection with multiresistant organisms has complicated the management of these infections and poses new risks to health care workers. Part 1 of this two-part series on AIDS discusses the pathophysiology and clinical expression, epidemiology, laboratory testing, and the general clinical manifestations of AIDS, as well as dermatologic, pulmonary, and cardiac symptoms. Part 2 will discuss the gastrointestinal, neurologic, and ocular symptoms, as well as the treatment and management of the AIDS patient.

The impact of a regionalized trauma system on trauma care in San Diego County.

A review of autopsy reports on traumatic deaths in 1986 was conducted to determine the impact on trauma mortality of the regionalized trauma system instituted in San Diego County in 1984. Determination of preventable death was made by a panel of experts and compared with an identical review of traumatic deaths in 1979, five years before the institution of regionalized trauma care. Of 211 traumatic deaths reviewed from 1986, two (1%) were classified as preventable, compared with 20 of 177 (11.4%) deaths in 1979 (P less than .001). A breakdown of trauma deaths into central nervous system and noncentral nervous system categories revealed the overall decline was in large part a consequence of the decline in non-central nervous system deaths from 16 of 83 in 1979 to one of 62 in 1986 (P less than .005). The decrease in central nervous system-related preventable deaths from four of 94 in 1979 to one of 149 in 1986 (P less than .10) was not statistically significant. Although it is likely the trauma system introduced in 1984 contributed to the decline in preventable death, it is not possible to isolate this variable from other changes that occurred during the interval between studies. A review of trauma deaths over the same time interval in a community with similar demographics but without a trauma system might help determine the relative contribution of the trauma system.

Emergency medicine: activated charcoal-the first-line agent in cases of overdose.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in emergency medicine. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers, or scholars to stay abreast of these items of progress in emergency medicine that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on Emergency Medicine of the California Medical Association and the summaries were prepared under its direction.