By: Jeffrey Rixe, M.D.

Knee Dislocation
-Tibio-femoral dislocation (50% anterior, hyperextension) (25% posterior, high impact mechanism)
-40% popliteal artery injury
-25% peroneal nerve injury
-“Dimple” Sign: medial condyle of femur stuck in joint capsule (needs OR reduction)
-50% self reduction. Think: Did this person with joint instability post-fall have a dislocation?
-No pulse or hard signs of vascular injury -> Call vascular
-Good pulses, ABI >0.9, admit for observation and Doppler
-Weak pulses, ABI <0.9, arteriography
–Further reading at Orthobullets.com

Pediatric Cases
-Case 1: 6F abdominal pain -> gastric bezoar  (Rapunzel Syndrome). Read beyond the gas in a KUB! Consult GI and surgery for endoscopic or open removal
-Case 2: 16F fatigue, alopecia, weight loss (“B symptoms”). Get a a CXR -> Mediastinal mass, Hodgkin lymphoma (most common CA 15-19 years). CT Chest/Abdomen/Pelvis to screen for masses and compression.

Pediatric C-spine
-Anatomic differences: Larger heads, shallow facets (can twist, sublux)
-Kids <8 yr more likely to have high C1-C2 injury , also more likely to have ligamentous injury
-Canadian C-spine: cannot use in < 16 years
-NEXUS: Enough cases in the 8-18 yr age range to make this applicable
-“Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger”

Hale DF, et al. J Trauma Acute Care Surgery. May 2015. PubMed
-NO IMAGING IF: NOT intubated, NOT comatose, NO neuro deficit, NO pain, NO torticollis
-X-ray C-spine in kids: 90-100% sensitive
-Negative x-ray? CT ONLY upper c-spine or MRI (no radiation)

Head CT Adults
-Can EM physicians read Neuro films? ~25% clinically significant misinterpretations (EM compared to radiology)
-Approach to Head CT in Trauma
-“Blood (blood) Can (cisterns)  Be (brain) Very (ventricles) Bad (bone)”
-Epidural – between suture lines, rupture of middle meningeal artery
-Sutures – coronal, sagittal, lambdoid, squamal (temporal)
-Cisterns – supracellar (STAR), circumesenphalic, quadrgeminal (W), sylvian
-Ventricles – lateral, third, fourth
-Fracture: linear, cortex disruption. Suture: jagged, cortex continuous

Pediatric Trauma
-Differences in children (compared to adults)
-A: Airway – floppy epiglottis, anterior position, Child <1yr use 3.0 cuffed
-B: Breathing – less bulk, more chest wall compliance, lower functional residual capacity (FRC)
-C: Circulation – watch changes in urine output or mental status, kids can lose ~35% effective blood volume before dropping BP (normal SBP = 80 + 2 x age). Watch for unexplained tachycardia
-D: Disability. A (spontaneously alert), V (response only to voice), P (responds to pain), U (unresponsive)
E: Exposure. Keep child warm. Triad: coagulopathy, hypothermia, acidosis

PECARN Head CT Rule (mdcalc.com)
– No CT if.…GCS 15, NO AMS, NO palpable skull fracture, NO high mechanism injury, NO signs basilar skull fracture, NO severe headache, NO vomiting
–Excellent Visual Decision Aid from ALiEM

The Seat Belt Complex Injury
– “Seat belt sign” 3x risk of abdominal injury, 50% spinal injuries
– Most common injuries: mesentery, bowel, pancreas

Waddell Triad (kid hit by car): femur fracture + abdominal injury + head injury
Duodenal hematoma : presents 2-3 days after handlebar bike injury

Podiatry Grand Rounds
– Physical Exam: Look for asymmetry. DP, PT, popliteal pulses. Vibratory and point sensation. ROM.
– Achilles tendon rupture: positive Thomson’s (calf squeeze) test
– Ottawa Ankle Rules (mdcalc.com)
– Calcaneal fracture: watch for concomitant spine injury
– Toe fracture with >50% nail hematoma – nail removal may be required
(Although listen to EMRAP on Nailbed injuries this month for additional perspective https://www.emrap.org/episode/penetratingthe/nailbedinjuries)
-High risk for compartment syndrome: calcaneal, lisfranc, (most common in tibial fractures)
– Major pathogens in DM foot infections are gram positive

PECARN Head CT rules v Clinical Suspicion
-Children <2 yr: PECARN sensitivity 100%, Clinical suspicion sensitivity 60%
– Children >2 yr: PECARN sensitivity 96% Clinical suspicion sensitivity 64%
– Listen to EMRAP this month: https://www.emrap.org/episode/penetratingthe/paperchase4
– Bottom Line: The PECARN traumatic brain injury rules had better sensitivity but lower specificity when compared with physician gestalt for clinically significant traumatic brain injury in children with minor blunt trauma.
– Additional reasons to use PECARN Rules: Decrease unnecessary CT imaging, decrease practice variation, mitigate racial/ethnic disparities in imaging

Safety of deferred CT
– Conclusion:  deferred CT scanning in intoxicated patients is likely a safe practice, although this study had severe limitations (retrospective, ICD 9 coding for inclusion, no follow up) and does not quite address the question.
– Remember to read the methods of any paper you reference or plan to use clinically

Traumatic Brain Injury 2016 Guidelines
– Steroids are not beneficial in TBI
– No evidence based guidelines on hypertonic saline or mannitol (insufficient evidence)
– Avoid hypotension (Keep SBP >110)
-Insufficient evidence to recommend levertiracetam compared with phenytoin regarding efficacy in preventing post-traumatic seizures and toxicity
–Full Traumatic Brain Injury 2016 Guidelines 

Resident Author: Jeffrey Rixe, MD 

Photo Credit: https://www.flickr.com/photos/lupuca/8720604364