Carolinas Core Concepts Core Concepts in EM; a repository for Carolinas lecture summaries.


Board Review: Dermatology and MSK

David Pearson, MD

  • Unlike older children, neonatal impetigo may present with bullae
  • Spectrum of disease
    • Erythema multiforme major - <10% total body surface area (TBSA)
    • Stevens Johnson's Syndrome - 10-30% TBSA
    • Toxic epidermal necrolysis - >30% TBSA
  • Cervical disc herniation occurs at C6-7 in approximately 70% of cases
  • Base of thumb fractures
    • Rolando - comminuted and intra-articular
    • Bennett - intra-articular and dislocation of the base of 1st metacarpal

Ligamentous Injuries of the Knee

Katherine Mahoney, MD

  • When injury to the knee causes immediate joint dysfunction, the injury will almost always be to the ACL or PCL.
  • Lateral collateral ligament injury will take up to 24 hours to swell and cause dysfunction.
  • In PCL injuries and knee dislocations, careful assess for neurovascular injury.
  • Unhappy triad: ACL, MCL, Medial Meniscus
    • Evaluate for associated injuries in the presence of any of the three injuries.

Pediatric Textbook Review – Lower Extremity Fractures and Upper Airway Management

Lee Garvey, MD

  • Toddler’s fractures may be missed on the normal two views. Consider getting an oblique view.
  • Pediatrics upper airway management requires significant forethought. Have your second and third backups ready.
  • For suspected epiglottitis, do NOT agitate the child until ENT/anesthesia available. NO IVs, NO meds, just transfer.
  • Proper documentation for likely viral URI
    • Position of uvula
    • Erythema of tonsillar pillars
    • Symmetry of tonsils
    • No pain on external manipulation of larynx
    • No trismus

Thoracic Cage Fractures

Katie Sprinkel, M.D.

  • Rib fractures are a marker of injury severity, having a single fracture on CXR confers a four fold increase in mortality. They should prompt you to look for other injuries.
  • Pediatric rib fractures, especially under 3 years old, should prompt investigation into child abuse.
  • Elderly patients do poorly (they have more rib fractures w/ low mechanisms and have increased rates of pneumonia/ARDS) so expect this and escalate their care accordingly.
  • The cornerstone of treatment for rib fractures is pain control sufficient to allow patients to continue to breathe deeply.
  • Sternal fractures when isolated are relatively benign but should prompt consideration of other injuries, especially T spine fractures and cardiac complications.
  • Not all clavicle fractures should be managed conservatively. Get ortho involved for skin tenting, 1.5-2 cm shortening, visible deformity, type 2 lateral fx, neurovascular injury.


Fragility Fractures “Small Fall, Large Costs”

  • Plain films miss fractures; 3.1% of all ED patients with "negative" hip x-ray studies actually have an occult hip fracture. If still clinically suspicious, MRI is the gold standard in low energy falls.
  • Having an organized, streamlined process to admit fragility fractures with goal of time to surgery less than 24 hours improves mortality, decreases length of stay and costs, and allows for earlier mobilization.
    • Dominquez S. et al. Prevalence of traumatic hip and pelvic fractures in patients with suspected hip fracture and negative initial standard radiographs—a study of emergency department patients. Academic Emergency Medicine. 2005 Apr; 12(4):366-9
    • Verbeeten KM, et al. The advantages of MRI in the detection of occult hip fractures. Eur Radiology. Jan 2005: 15(1): 165-9
    • Cannon J, Silvestri S. Munro M. Imaging choices in occult hip fracture. J Emergency Medicine. 2009 Aug; 37 (2): 144-52
    • Kates SL, Mears SC. A guide to improving the care of patients with fragility fractures. Geriatric Orthopaedic Surgery and Rehabilitation. 2011 2(1) 5-37