Figure 1. Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9601
Figure 1. Case courtesy of Dr Hani Makky ALSALAM, Radiopaedia.org, rID: 8720
Stress fracture at the distal tibial metaphysis – note the faint sclerotic line at the tibial metaphysis (Figure 2).
Figure 2. Arrows identifying the stress fracture. Case courtesy of Dr. Hani Makky Al Salam, Radiopaedia.org, rID: 8720
When coupled with the amenorrhea, consider the female athlete triad.
Plain film ankle views should be obtained. If a stress fracture is acute, sensitivity on plain films can be as low as 10% [6]. MRI can be performed outpatient with a sensitivity approaching 100% [4,5,7,8]. A pregnancy test should be performed as well given the amenorrhea. A standard workup for amenorrhea should be performed as an outpatient. Inquire about eating habits and anxiety/depression.
The three components of the female triad are on a spectrum of severity in the disruption of bone mineral density/osteoporosis, menstrual dysfunction/dysmenorrhea, and low energy with or without an eating disorder [1,9-11]. Patients will have a degree of dysfunction of all three components.
Stress fracture treatment included rest and analgesics. Immobilization is not necessary, but refraining from activity which exacerbates pain is crucial. NSAIDs may be used for pain control [5,7]. Female athlete triad is multifactorial and outpatient follow up should be ensured. Referral to adolescent medicine, sports medicine, or close primary care follow up is important.
Check out ALiEM’s SplintER Series to brush up on other can’t miss diagnoses of ankle pain.
Have you ever been working a shift at 3 am and wondered, “Am I missing something? I’ll just splint and instruct the patient to follow up with their PCP in 1 week.” This can be a reasonable approach, especially if you’re concerned there could be a fracture. But we can do better. Enter the “Can’t Miss” series: a series organized by body part that will help identify common and catastrophic injuries. This list is not meant to be a comprehensive review of each body part, but rather to highlight and improve your sensitivity for these potentially catastrophic injuries. We reviewed the approach to the pediatric elbow previously. Now, the “Can’t Miss” pediatric elbow injuries. (more…)
A 30-year-old female presents with left second finger pain with overlying erythema, warmth, and swelling the day after her cat bit her finger. She cannot fully extend the finger, it is tender and she has pain when it is passively extended. Her hand appears as shown above (Figure 1. Case courtesy of Kristina Kyle, MD).
Figure 1. Image prompt: AP view of the pelvis and left hip. Authors’ own images.
A 70-year-old male presents with left hip pain and inability to ambulate after a mechanical trip and fall. Examination demonstrates that the left lower extremity is shortened, abducted and externally rotated. Hip and pelvis x-rays are obtained (Figure 1).
This is EMRad, a series aimed at providing “just in time” approaches to commonly ordered radiology studies in the emergency department [1]. When applicable, it will provide pertinent measurements specific to management, and offer a framework for when to get an additional view, if appropriate. We recently covered the adult elbow, here we will cover the approach to the pediatric elbow.
Figure 1: Measurement of apical angle of the anterior fat pad ≥ 20 degrees, concerning for sail sign. There is also a visible posterior fat pad. Case courtesy of Dr. Ian Bickle, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
Figure 2: Lateral and AP x-rays of the elbow demonstrating humerus (green), radius (violet), and ulna (blue). Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. Annotations by Daniel Ichwan, MD.
Figure 3: Salter-Harris Classification. Case courtesy of Dr. Matt Skalski, Radiopaedia.org.
Figure 4: Ossification centers on (a) AP pediatric elbow x-ray (case courtesy of Dr. Leonardo Lustosa, Radiopaedia.org) and (b) lateral pediatric elbow x-ray. Note that not all ossification centers are visible in this view (case courtesy of Dr. Ian Bickle, Radiopaedia.org. Figure 6 (b) annotations by Daniel Ichwan, MD
Table 1: Order and timing of appearance of elbow ossification centers. Some people remember this order by using the mnemonic “CRITOE”: capitellum, radial head, internal (medial) epicondyle, trochlea, olecranon, and external (lateral) epicondyle.
Figure 6: Lateral oblique x-ray of the elbow. Case courtesy of Dr. Craig Hacking, Radiopaedia.org.
