A 44 year old woman with a past medical history of kidney stones and diabetes presents to the ED with 3 days of intermittent flank pain for which Tylenol is not helping. On exam, she is crying and in pain with some tenderness in RLQ and suprapubic area. No CVA tenderness noted. She denies fever and dysuria. A CT abdomen and pelvis with IV contrast was obtained and shown below. What’s the diagnosis?

Answer: bilateral emphysematous pyelonephritis (Findings: bilateral xanthogranulomatous pyelonephritis. Right perinephric stranding. Gas within both renal collecting systems and urinary bladder.)

This is a severe necrotizing infection of the kidney parenchyma. Primarily, cases occur in those with uncontrolled diabetes (95%) and a secondary factor is kidney obstruction (25-40%). The usual bacteria involved is E. Coli (69%) or K. Pneumoniae (29%). If caught early medical management of kidney function and antibiotics is the primary mode of treatment. Failure of initial treatment can lead to a nephrectomy.

• Class 1: gas in the collecting system only
• Class 2: gas in the renal parenchyma without extension to extrarenal space
• Class 3A: extension of gas or abscess to perinephric space
• Class 3B: extension of gas or abscess to pararenal space
• Class 4: bilateral EPN or solitary kidney with EPN

Management: admit for IV antibiotics and urological consult

This particular case has Proteus as the infective species as evident by staghorn calculi and urine culture. Because of preserved kidney function (Cr 0.87) and WBC (4.45), Urology elected to monitor and treat infection first and schedule outpatient procedure for stone removal to prevent urosepsis.

References:

Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27;160(6):797-805. doi: 10.1001/archinte.160.6.797. PMID: 10737279.

Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011 May;107(9):1474-8. doi: 10.1111/j.1464-410X.2010.09660.x. Epub 2010 Sep 14. PMID: 20840327.

A 40 year old male presents for right wrist pain. Onset was just before arrival when he was lifting at work, “felt a pop”, and had a sudden onset of pain. Exam reveals swelling and tenderness of the right wrist. Neurovascular exam is normal. A right wrist x-ray is performed and shown below. What’s the diagnosis?

Answer: Scapholunate Dissociation

• Background
  • Scapholunate ligament is most commonly injured ligament in the wrist
  • SLD is part of a spectrum of traumatic carpal bone instabilities
• Etiology
  • Most commonly occurs with FOOSH injury causing forceful wrist extension, rupturing the scapholunate interosseous ligament
  • Also associated with spastic paresis, rheumatoid arthritis, and congenital ligament laxity
• Presentation
  • Wrist swelling and point tenderness over dorsal aspect of wrist
  • Pain with wrist extension, radial deviation, and “clicking” sensation with movement
• Diagnosis
  • Obtain AP and lateral views (+/- grip compression view/wrist in ulnar deviation)
  • Radiographic signs:
    • Widening of the scapholunate joint space > 3mm (“Terry Thomas sign”)
    • Cortical ring sign – loss of ligamentous support results in rotary subluxation and palmar tilt of the scaphoid on AP radiograph 
  • MRI provides definitive diagnosis, rarely done in ED 
• ED Management
  • Pain management
  • Radial gutter splint
  • Urgent referral to orthopedics/hand specialist 
• Pearls and Pitfalls
  • Prompt recognition crucial
  • Delayed diagnosis is associated with chronic pain, joint instability, inflammatory arthritis, long-term degenerative changes

References:

Casey PD, Youngberg R.Scapholunate dissociation: a practical approach for the emergency physician.J EmergMed. 1993;11(6):701-707. doi:10.1016/0736-4679(93)90629-l

Long B, Koyfman A. Wrist Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, StapczynskiJ, Cline DM, ThomasSH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed September 29,2020.https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=222324635

Ramponi D, McSwigan T. ScapholunateDissociation.Adv Emerg Nurs J. 2016;38(1):10-14.doi:10.1097/TME.0000000000000094

Stevenson M, Levis JT. Image Diagnosis: Scapholunate Dissociation.Perm J. 2019;23:18-237. doi:10.7812/TPP/18-237

A 29 year old male with no past medical history presents with sudden onset, pleuritic chest pain radiating to right flank while swimming yesterday. He notes associated dyspnea, particularly with deep inspiration. Social history is notable for smoking tobacco and marijuana. Vital signs are: Temp 98.7F, HR 54, BP 125/76, RR 16, SpO2 98% RA. Exam shows a thin appearing male in no acute distress with clear bilateral lung sounds. A CXR is obtained and shown below. What’s the diagnosis?

Answer: Spontaneous Pneumothorax (see pleural line at apex of right lung)

• Is there an association between smoking marijuana and spontaneous pneumothorax (PTX)?
  • A brief literature review showed multiple cases but no studies proved causality.^{2, 3} However, one case control study had evidence that patients with spontaneous PTX and marijuana smoking history were at higher risk for poorer outcomes such as having larger pneumothoraces, prolonged post-op stays, and recurrence.¹

• Treatment: Depends on clinical status and size of PTX
  • Tension PTX = immediate needle decompression followed by thoracostomy
  • Supplemental O₂
  • Observation for small primary spontaneous PTX (<2 cm between lung margin and and chest wall) with no significant dyspnea OR asymptomatic patient with large primary spontaneous PTX (>2 cm) with serial CXRs
  • Chest tube insertion site: within the “triangle of safety” (see figure below)

References:

1. Stefani A, Aramini B, Baraldi C, Pellesi L, Della Casa G, Morandi U, Guerzoni S. Secondary spontaneous pneumothorax and bullous lung disease in cannabis and tobacco smokers: A case-control study. PLoS One. 2020 Mar 30;15(3):e0230419. doi: 10.1371/journal.pone.0230419. PMID: 32226050; PMCID: PMC7105102.

2. Manasrah N, Al Sbihi AF, Al Qasem S, Naik R, Hettiarachchi M. Recurrent Spontaneous Pneumothorax Associated With Marijuana Abuse: Case Report and Literature Review. Cureus. 2021 Feb 7;13(2):e13205. doi: 10.7759/cureus.13205. PMID: 33717745; PMCID: PMC7943398.

3. https://doi.org/10.1016/j.chest.2020.05.026

4. Dynamed, AMBOSS

A 36 year old male presents with left lower extremity pain after a motor vehicle vs pedestrian accident. The patient was crossing a crosswalk when a car hit him at low speed. On exam, there is an obvious deformity with significant swelling and tenderness of the left lower leg. What type of fracture pattern is present and what delayed surgical emergency can potentially occur from this injury?

Answer: Comminuted displaced fractures of distal tibia and fibula – high risk for development of Acute Compartment Syndrome

• After a fracture, there can be extravasation of blood with increased tissue swelling and venous flow impairment within the fascial compartments. The build up in pressure causes circulatory compromise, neurologic damage, and muscle necrosis. 
• The most common site of compartment syndrome is in the lower extremities at the tibia and fibula with a majority of cases occurring in the anterior compartment. Acute compartment syndrome can occur within a few hours of inciting trauma and can present up to 48 hours after.
• Patient’s typically feel pain out of proportion to exam with a tense “wood-like” compartment. Alarming symptoms include:
  • Pain with passive or active stretching (most sensitive exam finding)
  • Active contraction against resistance
  • Direct pressure over the compartments
• Diagnosis:
  • Exam findings can be sufficient to make the diagnosis in the correct setting of an inciting event along with alarming symptoms.
  • Using intracompartmental pressures alone as a guide, <30 mmHg would not require intervention whereas pressure >45 mmHg requires decompression.
  • Obtaining the “delta pressure” between the direct compartment pressure and diastolic pressure, a difference <30 mmHg should warrant fasciotomy.
• Rapid diagnosis is key as within 3-4 hours in the muscle there can be reversible change and after 8 hours there is irreversible muscle damage; in the nerve, as soon as within 2 hours patients can have loss of nerve conduction and within 8 hours there is irreversible damage.
• Treatment:
  • Immediately remove restrictive casts or dressings and place affected limbs at the level of the heart.
  • Surgical fasciotomy to reduce compartment pressure in a timely fashion.
    • These wounds post operatively are left open for a second operating room look within 48-72 hours for wound closure.
  • If delay in treatment, patient’s can have functional impairment including permanent neuropathy and contractures.

References:

Tintinalli’s Emergency Medicine (9th ed). Mayersak, R. J. McGraw Hill, 2018. Chapter 267 and 278. Page 1782, 1876-1879 

Torlincasi AM, Lopez RA, Waseem M. Acute Compartment Syndrome. [Updated 2023 Jan 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448124/

A 45 year old male with a history of ESRD on hemodialysis and insulin dependent diabetes presents with left knee pain after slipping at work. Vitals are within normal limits. On exam, the left lower extremity is distally neurovascularly intact with palpable distal pulses. There is obvious swelling over the knee with the worst pain superior to the patella. He is unable to extend the lower leg. An x-ray is performed and shown below. What’s the diagnosis?

Answer: quadriceps tendon rupture

• At first glance, lateral XR does not show obvious deformity… however, you may notice calcifications just superior to the patella representing retracted tendon.
• Quadriceps tendon ruptures tend to occur in individuals > 40, while patellar tendon ruptures occur more frequently in individuals < 40.
  • Overall, quadricep tendon ruptures are more common (risk factors include rheumatologic disease, renal failure, DM, chronic steroid use).
• In both injuries, classic exam finding is inability to extend the knee. You can often palpate a defect just above the patella in quadriceps tendon ruptures.
• High riding patella (“patella alta”) on lateral films is more frequently seen in patellar tendon ruptures. Low riding patella (“patella baja”) may be seen on lateral film with complete quadricep tendon tear (intact patellar tendon displaces patella inferiorly).
• X-rays may be normal! Ultrasound is the diagnostic modality of choice in the ED as it has both high sensitivity and specificity.
• Orthopedic consultation is always warranted for these cases. Management involves a knee immobilizer and prompt follow up. Early surgical repair is associated with better outcomes in severe cases.

References:

Bengtzen RR, Glaspy JN, Steele MT. Knee Injuries. In: Tintinalli JE, Stapczynski JS, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill; 2016: (Ch) 274. 

Pope JD, El Bitar Y, Mabrouk A, et al. Quadriceps Tendon Rupture. [Updated 2023 Apr 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482389/

A 63 year old male presents for “floaters” in his right eye for two weeks. He wears reading glasses at baseline. He denies pain or known injury to the eye. On exam, his visual acuity is 20/30 OD, 20/20 OS corrected with reading glasses. Pupils are equal, round, and reactive to light. IOP is 8 OD, 9 OS. There are no areas of focal uptake with fluorescein stain. POCUS of the right orbit is shown below. What’s the diagnosis?

Answer: Posterior Vitreous Detachment and Vitreous Hemorrhage (bright echogenic membrane horizontally across the posterior chamber not attached at the optic nerve and multiple free-flowing areas of varying hyperechogenicity that are mobile with eye movement)

• Presentation may vary from sudden onset floaters and generalized hazy vision to complete vision loss depending on severity
• May sometimes be a precursor to a retinal detachment
• Important to distinguish from a retinal detachment which will demonstrate a “V” shaped echogenic membrane attached to the optic nerve on POCUS
• Management is ophthalmology consultation especially if retinal detachment is suspected as it is a true ophthalmologic emergency

References:

Walker R.A., & Adhikari S (2020). Eye emergencies. 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. 

Lahham, S., Ali, Q., Palileo, B. M., Lee, C., & Fox, J. C. (2019). Role Of Point Of Care Ultrasound In The Diagnosis Of Retinal Detachment In The Emergency Department. Open access emergency medicine : OAEM, 11, 265–270. https://doi.org/10.2147/OAEM.S219333

www.emra.org/emresident/article/floaters-retinal-detachment-posterior-vitreous-detachment-or-vitreous-hemorrhage