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.

Emergency medicine clerkship curriculum: an update and revision.

In 2006, the latest version of a national curriculum for the fourth-year emergency medicine (EM) clerkship was published. Over the past several years, that curriculum has been implemented across multiple clerkships. The previous curriculum was found to be too long and detailed to cover in 4 weeks. As well, updates to the Liaison Committee on Medical Education (LCME)'s form and function document, which guides the structure of a clerkship, have occurred. Combining experience, updated guidelines, and the collective wisdom of members of the national organization of the Clerkship Directors in Emergency Medicine (CDEM), an update and revision of the fourth-year EM clerkship educational syllabi has been developed.

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.

The use of health care policy to facilitate evidence-based knowledge translation in emergency medicine.

Health care policy can facilitate emergency medicine knowledge translation (KT). Because of this, the 2007 Academic Emergency Medicine Consensus Conference on KT identified a specific theme regarding issues of health care policy and KT. Six months before the Consensus Conference, international experts in the area were invited to communicate on health care policies regarding all areas of KT via e-mail and "Google groups." From this communication, and using available evidence, specific recommendations and research questions were developed. At the Consensus Conference, additional comments were incorporated. This report summarizes the results of this collaborative effort and provides a set of recommendations and accompanying research questions to guide development, implementation, and evaluation of health care policies intended to promote KT in emergency medicine. The recommendations are to 1a) involve appropriate stakeholders in the health care policy process; 1b) collaborate with policy makers when health care policy focus areas are being developed; 2) use previously validated clinical practice guideline development tools; 3) address implementation issues during the development of health care policies; 4) monitor outcomes with performance measures appropriate to different practice environments; and 5) plan periodic reviews to uncover new clinical evidence, new methods to improve KT, and new technologies. To advance the further development of these recommendations, a research agenda is proposed.

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.