PV Card: Adult scaphoid fracture

$snuffbox tenderness scaphoid fracture$ What is the most commonly fractured carpal bone in adults? It’s the scaphoid bone. As a bonus it has the dreaded complication of avascular necrosis. So how good are the physical exam and imaging modalities in diagnosing a fracture? What is the likelihood ratio (LR) that snuffbox tenderness predicts a fracture? Bottom lines: The exam is highly sensitive but poorly specific, such that one can only confidently state that a NON-tender snuffbox and scaphoid tubercle essentially rule out an acute scaphoid fracture. Also negative x-rays for patients with scaphoid tenderness still yield a fracture post-test probability of 25%. This PV card breaks down all the LRs.¹

PV Card: Scaphoid Fracture

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Adapted from ¹

Reference

Carpenter C, Pines J, Schuur J, Muir M, Calfee R, Raja A. Adult scaphoid fracture. Acad Emerg Med. 2014;21(2):101-121. [PubMed]

By Sean Kivlehan, MD MPH|2021-10-04T09:47:50-07:00Feb 1, 2016|ALiEM Cards, Orthopedic|

Trick of the Trade: Extra-oral reduction technique of anterior mandible dislocation

Anterior dislocation of the mandible is a clinical scenario that is not infrequently encountered by the ED provider and requires prompt intervention. The classic technique for reduction of the mandible requires the provider to place his/her thumbs or fingers into the patient’s mouth along the lower molars and apply force inferiorly and posteriorly. However, this technique is fraught with difficulties and inefficiencies including the following:

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By Kara Toles, MD|2023-06-15T16:19:45-07:00Jan 26, 2016|ENT, Tricks of the Trade|

PEM Pearls: Assessing Radiation Risk in Children Getting CT Imaging – Managing Risk and Making Medical Decisions

The Case: A 5 year old girl presents to the ED with approximately 24 hours of suprapubic and RLQ abdominal pain. Vital signs are: Temp 38.2 C, HR 110, RR 19, BP 100/60, Oxygen Sat 100% on room air. She has vomited twice but has not had diarrhea. She had a history of constipation a year ago that has resolved and mother denies any urinary symptoms or history of UTI’s. The patient is quiet but nontoxic appearing. Your abdominal exam notes mild to moderate RLQ tenderness but no rebound and normal bowel sounds. You order a urinalysis, which is negative and a RLQ US which ‘does not visualize the appendix’. Your suspicion for possible appendicitis is still intermediate; however, now the patient states she is “a little hungry”. Should you order a CT of the abdomen and pelvis? Uuugh!

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By Robert Cloutier, MD MCR|2026-06-16T16:08:43-07:00Jan 25, 2016|CME, Pediatrics, PEM Pearls, Radiology|

Trick of the Trade: Patient positioning for ultrasound-guided ulnar nerve block

Patients with 5th metacarpal fractures (commonly termed “boxer’s fracture”) are frequently treated in the emergency department (ED) with closed reduction and splinting. Obtaining analgesia and a successful closed reduction can often be challenging without procedural sedation. Severe swelling can make a hematoma block difficult, often resulting in inadequate analgesia. An ultrasound-guided ulnar nerve block provides a simple method to facilitate pain relief and allow for improved fracture site manipulation.

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By Kara Toles, MD|2018-10-28T21:25:09-07:00Jan 20, 2016|Tricks of the Trade, Ultrasound|

Diagnose on Sight: Shortness of Breath

Case: 55-year-old restrained driver is reporting severe shortness of breath and right sided chest pain after a high-speed motor vehicle collision. Her respiratory rate is 26 breaths/min and her oxygen saturation is 96% on a 15-liter non-rebreather. She has decreased breath sounds on the right, epigastric tenderness, and an abdominal seatbelt sign. What is the diagnosis?

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By Sarah G. Sifuentez MD|2026-06-16T16:08:35-07:00Jan 18, 2016|Diagnose on Sight, Trauma|

Trick of the Trade: Isopropyl Alcohol Vapor Inhalation for Nausea and Vomiting

Your triage nurse complains of numerous patients in the waiting room complaining of nausea, retching, and emesis. They ask you “why can’t we have an antiemetic on hand in triage?” Turns out they might have had an effective antiemetic on hand, or rather in their scrub pocket the entire time. They just didn’t know about it yet.
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By Mark Culver, PharmD, BCPS|2026-06-16T16:08:37-07:00Dec 21, 2015|Expert Peer Reviewed (Clinical), Gastrointestinal, Tricks of the Trade|

PEM Pearls: Cardiac causes of pediatric chest pain

Children with chest pain commonly present to the emergency department. Both the child and family members may think their symptoms are due to a serious illness. Among adolescents seen for their chest pain, more than 50% thought they were having a heart attack or that they had cancer.¹ In reality, only 6% of pediatric chest pain has a cardiac etiology.² Nonetheless, extensive and costly emergency department (ED) evaluations are common and there is wide practice variation.³

But prior to reassuring your patient, what can you do to reassure yourself that your patient doesn’t need a more extensive workup? What would make you suspicious for cardiac causes of pediatric chest pain?

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By Delphine Huang, MD|2026-06-16T16:08:30-07:00Dec 14, 2015|Cardiovascular, CME, Pediatrics, PEM Pearls|