A 2 year old with no past medical history presents with severe left leg pain after falling off a trampoline. He is crying and refusing to bear weight or straighten his left leg. The extremity is otherwise neurovascularly intact. An XR of his left lower leg is shown below. What’s the diagnosis and specifically what type of fracture is it?

Answer: Salter-Harris type II fracture of the proximal left tibia

• Salter-Harris fractures are fractures of the growth plate, and there are 5 types which are commonly learned with the mnemonic SALTER

Salter Harris Type	Location	Management
1 (Slipped)	Epiphysis separated from metaphysis	Brace, follow up with pediatrician
2 (Above)	Extends though physis and into metaphysis	Splint, NWB, ortho follow up
3 (Lower)	Extends into intra-articular space	Splint, ED ortho consult
4 (Through)	Extends through metaphysis, physis, and epiphysis	Splint, ED ortho consult
5 (ERased)	Physis compression	Splint, ED ortho consult

References:

Mayersak R.J. (2020). Initial evaluation and management of orthopedic injuries. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

A 68 year old male with a history of DM, HTN, and breast cancer presents to the ED with progressively worsening dyspnea over the past three to four days. On exam she is tachycardic to 120, appears tachypneic with accessory muscle usage and pulse ox is 88% on room air. You perform a lung ultrasound which reveals the following:

What is the diagnosis?

Pleural Effusion.

Ultrasonographic findings of pleural effusion:

• Fluid appears dark (anechoic) cephalad to the diaphragm and may be homogeneous or heterogeneous depending on the etiology of the fluid.
• Lung may be seen as a triangle-like structure floating in the pleural fluid
• Thoracic spine sign: the spine is able to be visualized due to loss of mirror artifact as a hyperechoic area posterior to the fluid as the fluid acts a medium through which the ultrasound waves can be transmitted

Case continued:

A pigtail was placed to remove the fluid with the patient experiencing improvement in respiratory status status post drainage of approximately 800mL of fluid.

Resources:

Deschamps, Jade, and Vi Dinh. “Lung Ultrasound Made Easy: Step-By-Step Guide.” Pocus 101, 2023, www.pocus101.com/lung-ultrasound-made-easy-step-by-step-guide/. Accessed 6 Nov. 2024. Co-authors: Jessica Ahn, Satchel Genobaga, Annalise Lang, Victor Lee, Reed Krause, Devin Tooma, and Seth White. Oversight, review, and final edits by Vi Dinh.

Huang, Calvin, Andrew S. Liteplo, and Vicki E. Noble. “Lung and Thorax.” Practical Guide to Emergency Ultrasound, edited by Vicki E. Noble and Bret P. Nelson, 2nd ed., Cambridge University Press, 2011, pp. [specific page numbers if available].

A 51-year-old male with past medical history of HTN, DM presents with right shoulder pain. He states he tripped off the curb and landed on his right shoulder. On exam, there are no palpable deformities, but patient has limited abduction of shoulder and tenderness on palpation of anterior shoulder. An X-ray is obtained and shown below. What’s the diagnosis?

Answer: Acromioclavicular (AC) joint separation

• AC joint is composed of the acromion process and clavicle and supported by AC ligament, coracoclavicular ligament
• Mechanism of injury is fall directly on shoulder or FOOSH
• AC joint injuries range from sprain of ligaments to complete rupture of all supporting ligaments and complete separation of clavicle and acromion
  • Type I: normal X-ray, due to sprain of ligaments
  • Type II (X-ray above): widened AC joint, clavicle is displaced <50%, due to rupture of AC ligaments
  • Type III: clavicle displaced >50%, due to rupture of AC ligaments and coracoclavicular ligaments
  • Type IV: clavicle is dislocated posteriorly
  • Type V: clavicle displaced >200% superiorly
  • Type VI: clavicle dislocated inferiorly
• Treatment
  • Sling immobilization and physical therapy for types I – III
  • Surgical repair for types IV – VI

References:

Bjoernsen, Lars Petter, and Alexander Ebinger.. “Shoulder and Humerus Injuries.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016