Odontoid/Dens Fractures.

Odontoid fractures remain the most common C2 fracture and of those individuals older than 65 years. The type of optimal management remains in question given comorbidities, risk of nonunion, and limitations in mobility when surgical fusion is the treatment selected. These fractures are of particular importance, given the high incident of morbidity and mortality following an odontoid fracture. Overall quality of life remains a significant consideration when selecting the best intervention following careful examination and confirmation with radiographic imaging. The literature continues with controversies in the best treatment interventions for these fractures, resulting in a case-by-case decision-making process.

Perilunate and Lunate Dislocations.

Lunate and perilunate dislocations, although somewhat uncommon, are serious injuries and can be easily missed. The mechanism of injury is hyperextension of the wrist, often associated with a fall on the outstretched hand (FOOSH) injury, falls from height, or motor vehicle crash with a high-energy traumatic injury to the wrist. Perilunate dislocations typically present with pain and swelling over both the dorsal and volar aspects of the wrist and limited range of motion of the wrist. Perilunate dislocations result in disruption of the relationship between the lunate and the capitate, whereas lunate dislocations result in a disruption of the lunate bone, both from the radius and the capitate, primarily diagnosed on the lateral view of the wrist radiograph. These injuries require emergent reduction and stabilization either via a closed or open surgical reduction by an orthopedic specialist. Lunate dislocations can lead to long-term pain and disability if overlooked in their initial assessments.

Chest X-Ray Findings in Patients With COVID-19 Pneumonia.

Currently, there are limited research and reports on how a chest radiograph plays a role in the treatment of COVID-19 patients, but some of the findings up to now have demonstrated that they are useful in specific situations, such as when symptoms are severe, other testing is limited, and an acute outbreak occurs (Blain et al., 2021). As referenced by Rubin et al. (2020) a consensus statement made by the Fleischner Society recommended that imagining should not be ordered in patients with mild symptoms, but it can be used in diagnosing COVID-19 if deemed necessary. Chest radiography is a relatively inexpensive, quick imaging method with minimal radiation exposure for finding typical COVID-19 lesions such as ground glass opacities or consolidation findings as the viral infection progresses. Chest radiography can also be helpful in inpatient settings when there are possible superimposed complications such as pleural effusions or pneumothorax (Chalian, 2020).

Galeazzi Fracture-Dislocation.

A Galeazzi fracture-dislocation is defined as a distal radius fracture with disruption of the distal radioulnar joint (DRUJ). The typical mechanism of injury is a forceful axial load with forearm torsion, which is often seen in a fall on the out stretched hand (FOOSH). The diagnosis is made with radiographs of the distal forearm and the wrist. The diagnosis can often be missed because ligament disruption of the distal radioulnar joint (DRUJ) can be overlooked. Treatment in children is usually nonsurgical with closed reduction and long arm cast. Adult treatment is usually open reduction and internal fixation. Complications can result in disability and include malunion, limited range of motion of the forearm, chronic pain, DRUJ instability, and osteoarthritis.

Monteggia Fracture-Dislocation.

A Monteggia fracture-dislocation involves a proximal one-third of the ulna fracture with a concomitant dislocation of the radial head proximally at the elbow. This fracture and dislocation often results from a fall on the outstretched hand (FOOSH) low-energy mechanism of injury. One must have a high index of suspicion with any ulnar fractures to look for a radial head dislocation so that the dislocation component is not missed. These injuries often require early orthopedic intervention. Any delays in treatment can lead to poor long-term outcomes including chronic valgus instability and radiocapitellar osteoarthrosis.

Something's "Fishy" With That Sore Throat...

A 9-year old male presented to the emergency department for the evaluation of a sore throat. Initial history of present illness stated in the triage note was that "the child complained of a sore throat," suggesting possible pharyngitis. There was no evidence of stridor, sialorrhea, hypoxia, or aphonia. Further investigation of the history of present illness identified the concern for a possible esophageal foreign body. Imaging studies of the neck identified a fishbone in the esophagus. This case presentation discusses an atypical presentation of an esophageal foreign body and the subtle findings on assessment and imaging. This case highlights the importance of illiciting a history of present illness and the subtleties of esophageal foreign body identification.

Clavicle Fractures.

Clavicle fractures are commonly seen in children and young adults. A case of a 30-year-old woman sustaining a clavicle fracture while riding a bike is highlighted. The most common cause is strong fall with the injured arm at one's side, often in contact sports injuries. The clavicle is divided into thirds: medial (proximal), middle (midshaft), and lateral (distal) thirds. Eighty percent of clavicle fractures occur in the middle third of the clavicle, and nearly half of those midshaft fractures are displaced. Goals of initial treatment are to reduce pain and limit motion of the fracture fragments until bone union with either sling or figure-of-eight dressing. Surgical treatment has recently shown reduction of the nonunion rate and decreases the time for fracture union compared with nonsurgical treatment.

Proper Placement of Tubes on Chest Radiographs.

A variety of tubes are placed by the advanced practice provider including endotracheal tubes, nasogastric tubes, feeding tubes, and chest tubes. Recognizing the proper placement of these tubes is critical to prevent complications and allow for intended use including ventilation, nasogastric drainage, providing enteral nutrition, and drainage of air or fluid from the pleural space. The advanced practice provider must be aware of the anatomical landmarks that help indicate correct positioning for safe use and proper functioning of these tubes. This article will discuss how to assess for proper placement of endotracheal, nasogastric, and chest tubes.

Vaping: What Every Emergency Nurse Practitioner Should Know!

As of December 10, 2019, according to the Centers for Disease Control and Prevention (CDC), more than 2,668 hospitalized cases of lung injury and 60 deaths associated with use of electronic nicotine delivery systems, or "vaping." In many cases, patients required multiple health care visits prior to diagnosis. Recognition of the risk factors, symptoms, and examination findings that have been consistently reported is critical to making the diagnosis and initiating treatment early in the progression of disease. The precise mechanism and causative agent have yet to be elucidated, but the association with vaping has been established. Multidisciplinary collaboration among health care providers, poison centers, health departments, reference laboratories, and the CDC will be necessary to identify the cause and prevent further harm.

Mallet Finger.

This article provides an overview of issues associated with traumatic injury to the distal finger that results in extensor tendon disruption or bony avulsion at the base of the distal phalanx. Commonly referred to as mallet finger, drop finger, or baseball finger, terminal extensor tendon injuries are a common presentation to the emergency department. Providers need to be advised of evidence-based management of these extensor tendon injuries in order to prevent decreased function and permanent deformity. Current evidence supports nonoperative interventions, but injuries need to be addressed in a timely manner in order to avoid poor outcomes.

Sever's Disease (Calcaneal Apophysitis).

Sever's disease, or calcaneal apophysitis, is the primary cause of heel pain in pediatric patients between the ages of 8 and 15 years. Primary risk factors in pediatric athletes are obesity and high levels of physical activity. Sever's injury primarily results from high-impact sports such as soccer, track, cross-country, gymnastics, tennis, and ballet. This injury mainly occurs during puberty with an open growth plate in the immature calcaneus. Clinical diagnosis can be confirmed by performing a "squeeze test" of the heel on physical examination. Diagnostic imaging findings include increased sclerosis and fragmentation of the calcaneal apophysis on plain radiograph x-rays. Ice, activity restriction, stretching, nonsteroidal anti-inflammatory drugs, immobilization, and heel cups are all methods that can be utilized in treating the pain caused by Sever's. No long-term effects have been associated with Sever's disease.

Tibial Plateau Fractures.

Tibial plateau fractures can result from direct trauma or indirect compressive forces. These injuries often result in significant soft tissue disruption, ligamentous disturbance in addition to bone fractures. Diagnostic imaging findings in plain radiographs include fat-fluid level in the suprapatellar bursa, malalignment of the femoral condyles and tibial edges, and increased trabecular density in the lateral epicondyle. Patients in whom a tibial plateau fracture is suspected with negative radiographs should have computerized tomography imaging performed. Most patients will require surgical intervention for fracture fixations. Primary long-term complication includes posttraumatic osteoarthritis because of the traumatic stress forces across the joint.

Pneumoperitoneum.

Pneumoperitoneum, usually seen as free air under the diaphragm, is a finding that can be seen on plain abdominal radiographs, signifying a leakage of air, usually from a perforation in the gastrointestinal tract. There are several other potential pathways from other body compartments for air to enter the abdominal cavity. Pneumoperitoneum does not always signify bowel rupture, as it can also result from pneumomediastinum and pneumothorax, and in patients who are being mechanically ventilated. Patient history and physical examination can assist in a preliminary diagnosis before diagnostic imaging. Plain chest/abdominal radiograph or computed tomographic scan of the abdomen can be diagnostic of pneumoperitoneum. Surgical versus nonsurgical conservative observation is determined on the basis of the cause and amount of free air.

Hip Fractures.

Hip fractures are associated with significant morbidity and mortality and a major health problem in the United States (). Eighty percent of hip fractures are experienced by 80-year-old women. Plain radiographs usually confirm the diagnosis, but if there is a high level of suspicion of an occult hip fracture, magnetic resonance imaging or bone scan is the next step to confirm the diagnosis. Areas of the hip bone have varied bone strength and blood supply, making the femoral neck one of the most vulnerable areas for fracture. A consultation to an orthopedic surgeon will determine surgical interventions.

Orbital Floor Fractures.

The orbital bones are thin and exposed, making the orbital walls vulnerable to fractures. The floor of the orbit is the weakest portion of this 4-sided pyramid structure. Blunt force trauma is the primary mechanism of injury in young men between the ages of 18 and 30 years. Computerized tomography is the primary imaging technique to diagnose orbital fractures. Conservative versus surgical management is determined by maxillofacial and ophthalmology specialists.

Metatarsal Stress Fractures.

Metatarsal stress fractures are also called "march fractures" or "marcher's foot." They most commonly occur in the distal second and third metatarsals. The second and third metatarsals receive the majority of stress during ambulation and are less mobile compared with the other metatarsals. The predominant risk factor is excessive overuse with repetitive motions with little recovery time such as marching activities in the military. Any element that has a detrimental effect on bone density can predispose an individual to stress fractures. There is often a delay of 2 or more weeks from the onset of symptoms until visible fractures are able to be seen on radiographs. Initial treatment strategies involve rest, ice, nonweight bearing, and avoidance of exercise to prevent fracture displacement, nonunion, and other complications. Orthopedic referral will guide definitive care.

Chemical Burns of the Eye.

Chemical burns of the eye are one of the most common eye injuries. The extent of the ocular surface damage is influenced by the type, temperature, volume, and pH of the corrosive substance and duration of exposure. Limbal ischemia found on eye assessment is the primary determinant of eventual visual outcome. Eye irrigation must be instituted immediately at the scene of exposure and continued in the emergency department to reduce visual impairment. Traditionally lactated Ringer's and normal saline have been used as irrigation fluids, although one systematic review demonstrates similar outcomes with other irrigation fluids. The Morgan Lens is a device that can be utilized to allow the provider to perform "hands free" eye irrigation. Complications of chemical burns are more common with alkali burns as these substances destroy the corneal epithelium and allow this corrosive base substance to penetrate deeper into the cornea.

An Innovative Approach: Using Simulation to Teach Primary Care Gynecologic Procedures.

INTRODUCTION: In response to the growing body of evidence that simulation is a satisfactory way to instruct procedural skills, we developed an innovative model to teach common gynecologic procedures such as cervical cancer screening, cervical polyp removal, intrauterine device removal, and endometrial biopsy. The objectives of this study were to describe the construction of the model and to assess participants' satisfaction and confidence in applying the learning objectives to their clinical practice. METHODS: The researchers created the model with reusable and readily available materials. During a hands-on skills workshop, practicing clinicians performed simulated cervical cancer screening, endocervical polyp removal, intrauterine device removal, and an endometrial biopsy on a low-fidelity gynecologic model. Using convenience sampling, each participant completed a survey designed to measure satisfaction with the workshop and self-confidence in their newly acquired skills. RESULTS: All (N = 30,100%) of the participants agreed at the "agree" or "strongly agree" level that the gynecologic skills workshop using lecture and a hands-on model was a satisfying and self-confidence-building experience. CONCLUSIONS: An easily reproducible and reusable gynecologic procedure simulator was highly rated as a means of teaching common primary care gynecologic procedures. The simulated model provided an opportunity for hands-on skills learning for clinicians who wish to expand their gynecologic procedure skill set.

Dental Procedures.

Dental problems are a common complaint in emergency departments in the United States. There are a wide variety of dental issues addressed in emergency department visits such as dental caries, loose teeth, dental trauma, gingival infections, and dry socket syndrome. Review of the most common dental blocks and dental procedures will allow the practitioner the opportunity to make the patient more comfortable and reduce the amount of analgesia the patient will need upon discharge. Familiarity with the dental equipment, tooth, and mouth anatomy will help prepare the practitioner for to perform these dental procedures.

Dislocation of the Temporomandibular Joint and Relocation Procedures.

Temporomandibular joint (TMJ) dislocation requires prompt medical attention due to the crucial impact of airway, nutrition acquisition, and communication. Recognition of this injury by the practitioner, based on clinical presentation and history, is paramount for identification of accurate diagnosis and prompt treatment of TMJ dislocation. Relocation or reduction methods vary on the basis of the severity of the injury and whether it is an acute or chronic dislocation.