Orthopedic pitfalls in the ED: neurovascular injury associated with posterior elbow dislocations.

Posterior elbow dislocations are the most common type of elbow dislocation and are usually caused by a fall on an outstretched hand. Although the incidence of elbow dislocation complications is rare, the emergency physician is responsible for evaluation and identification of concomitant neurovascular injuries. Failure to identify neurovascular compromise after elbow dislocation or reduction can potentially lead to severe morbidity with limb ischemia, neurologic changes, compartment syndrome, and potential loss of limb. Cyanosis, pallor, pulselessness, and marked pain should suggest vascular injury or compartment syndrome, both requiring immediate intervention. Patients in whom it is not clear if there is vascular injury should undergo further imaging with angiography, considered the gold standard for evaluation of arterial damage. It is important for the emergency physician to maintain a high level of suspicion and evaluate for neurovascular compromise on every patient with elbow dislocation despite the low overall incidence of severe injury.

Bedside ultrasound for verification of shoulder reduction.

Shoulder dislocations are a common complaint in the emergency department. The management of these injuries is well described and often involves procedural sedation. Unfortunately, patients often recover from this sedation before radiographs can verify successful reduction. We describe 2 patients with glenohumeral dislocations and subsequent reduction immediately verified by bedside ultrasound before the patients' recovery from procedural sedation. Our experience suggests that ultrasound may reduce the need for repeated sedation, expedite care, and reduce costs.

Bedside sonography by emergency physicians for the rapid identification of landmarks relevant to cricothyrotomy.

INTRODUCTION: Cricothyrotomy is a difficult, infrequently performed lifesaving procedure. OBJECTIVES: The objectives of the study were to develop a standardized ultrasound technique to sonographically identify the cricothyroid membrane (CM) and to evaluate the ability of emergencyphysicians (EPs) to apply the technique in a cohort of Emergency Department (ED) patients. METHODS: Four cadaveric models were used to develop a technique to accurately identify the CM. Two EPs then sonographically imaged 50 living subjects. Time to visualization of the CM and relevant landmarks, as well as perception of landmark palpation difficulty, were recorded. RESULTS: Fifty subjects were enrolled, and relevant structures were identified in all participants. The mean time to visualization of the CM was 24.32 +/- 20.18 seconds (95% confidence interval, 18.59-30.05 seconds). Although a significant relationship between palpation difficulty and body mass index was noted, body mass index did not impact physician ability to identify the CM. CONCLUSIONS: Emergency physicians were able to develop and implement a reliable sonographic technique for the identification of anatomy relevant to performing an emergent cricothyrotomy.

Emergency physicians can easily obtain ultrasound images of anatomical landmarks relevant to lumbar puncture.

INTRODUCTION: Although ultrasound has been used in administering epidural anesthesia, it is unknown if emergency physicians (EPs) can obtain ultrasound images useful for lumbar puncture. OBJECTIVE: The objective of the study was to determine EPs' ability to apply a standardized ultrasound technique for visualizing landmarks surrounding the dural space. METHODS: Two EPs sought to identify relevant anatomy in emergency patients. Visualization time for 5 anatomical structures (spinous processes or laminae, ligamentum flavum, dura mater, epidural space, subarachnoid space), body mass index, and perception of landmark palpation difficulty were recorded. RESULTS: Seventy-six subjects were enrolled. Soft tissue and bony anatomical structures were identified in all subjects. Mean body mass index was 31.4 +/- 9.8 (95% confidence interval, 29.1-33.6). High-quality images were obtained in less than 1 minute in 153 (87.9%) scans and in less than 5 minutes in 174 (100%) scans. Mean acquisition time was 57.19 seconds; SD, 68.14 seconds; range, 10 to 300 seconds. CONCLUSION: In this cohort, EPs were able to rapidly obtain high-quality ultrasound images relevant to lumbar puncture.

Orthopedic pitfalls in the ED: tibial plafond fractures.

Fractures of the tibial plafond, or distal tibial articular surface, are usually associated with a high-force mechanism, which frequently can involve associated injuries and prolonged disability. Because of distracting injury and variations in clinical findings, tibial plafond fractures may be initially missed or misdiagnosed. This review examines the clinical presentation, diagnostic techniques, and management of tibial plafond fractures applicable to the emergency practitioner.