How many times have you had to look up the shoulder exam maneuvers for patients with acute shoulder pain? I don’t know why I just can’t seem to remember these.
This Paucis Verbis card is a quick reference card to remind you of the most common techniques. Thanks to Jenny for the idea.
Go to ALiEM (PV) Cards for more resources.
We’ve all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child’s arm is either broken or dislocated. We all recognize this as radial head subluxation or “nursemaid’s elbow” and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? What if nothing happens?
Is there an alternative technique to reducing a nursemaid elbow?
There is constant debate on whether to image the cervical spine of blunt trauma patients. Fortunately, there are two clinical decision tools available to help you with your evidence-based practice.
The NEXUS and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients.
| Sensitivity (%) | Specificity (%) | |
| NEXUS | 99.6 | 12.6 |
|---|---|---|
| CCR | 99.4 | 45.1 |
National Emergency X-radiography Utilization Study
A patient’s neck can be clinically cleared safely without radiographic imaging if all five low-risk conditions are met:
* Defined as “a condition thought by the clinician to be producing pain sufficient to distract the patients from a second (neck) injury. Examples may include, but are not limited to the following:
Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries.”
The basic approach in this flow-chart is to (1) make sure that the patient meets the same inclusion criteria as in the CCR study. Then (2) determine if there are high-risk findings. If so, go directly to imaging. (3) If there are no high-risk findings, check to see if the patient qualifies as a low-risk candidate where you might be able to clinically clear the c-spine without imaging. (4) If the patient is neither high or low risk, then the patient is moderate risk and requires imaging. Here’s a flow chart that I made to help you remember:
Go to ALiEM (PV) Cards for more resources.
Note: Many emergency physicians go straight to CT imaging for patients with neck tenderness and moderate/high risk findings. I personally rarely use the CCR algorithm because I can rarely remember all of the criteria. NEXUS is nice because of its simplicity. Where the CCR algorithm IS helpful is in clinical clearance of the low-risk patient with neck pain. I’ve cleared many patients who self-present with a whiplash mechanism (simple rear-end motor vehicle crash) and diffuse neck pain. By NEXUS criteria, you’d have to image them because they have neck tenderness. By CCR criteria, if they can actively rotate their neck 45 degrees left and right, they don’t have a clinically significant c-spine injury. No imaging needed.
There are many ways to relocate a shoulder dislocation. Most of these ways require procedural sedation. What if the risks of procedural sedation outweigh the risks? What alternative maneuver can you try, which only requires parenteral pain medications +/- an intra-articular lidocaine?
This is the second Paucis Verbis card on cervical spine fractures. Part 1 covered C1 and C2 fractures. This card covers the lower cervical spine fractures. These two tables are part of my chapter on “Spine and Spinal Cord Injury” in the textbook Emergency Medicine by Dr. Jim Adams (Northwestern EM Chair).
Go to ALiEM (PV) Cards for more resources.
I’m starting to work on co-authoring the next edition of my chapter on “Spine and Spinal Cord Injury” within the textbook “Emergency Medicine” by Dr. Jim Adams (Northwestern EM Chair). There are some useful tables that I created that I thought you might find helpful. This is the first installment covering C1-C2 fractures. The next PV card will cover the lower cervical fractures.
I always forget which are stable and unstable. For instance, the above extension teardrop fracture looks innocuous but is an unstable fracture because the anterior longitudinal ligament is ruptured.
Go to ALiEM (PV) Cards for more resources.
In the workup of monoarticular arthritis, the question that emergency physicians constantly struggle over is whether the patient has a nongonococcal septic arthritis. This joint infection alarmingly damages and erodes cartilage within only a few days.
This installment of the Paucis Verbis (In a Few Words) e-card series reviews the JAMA Rational Clinical Examination article which asks “Does this patient have septic arthritis?” Pooled sensitivities and likelihood ratios were calculated. These statistics are always helpful when trying to figure out the patients probability of having a septic joint.
I was surprised to learn that only about 50% of patients with septic joints have a fever. Note that a hip or knee prosthesis PLUS an overlying skin infection pretty much equals a septic joint (LR = 15.0).
Risk factors are listed in the table with the corresponding sensitivities, specificities, and likelihood ratios.
Go to ALiEM (PV) Cards for more resources.