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SplintER Series: A Collision at the Plate

Proximal avulsion fracture

A 17-year-old male baseball catcher presents with right knee pain after an opponent slid into home plate, striking the anteromedial aspect of the patient’s knee while it was in extension trying to block the plate. An x-ray of the tibia and fibula was obtained (courtesy of Dr. Haytham Bedier, Radiopaedia.org).

This is a proximal avulsion fracture of the styloid process of the fibula, indicating injury to the posterolateral corner (PLC) of the knee [1].

  • Pearl: In most cases, the avulsed fragment is attached to the lateral collateral ligament and/or the biceps femoris [2].

This injury usually occurs from varus stress in a hyperextended knee- think a blow to the anteromedial tibia with the knee in extension [2].

The arcuate sign is a horizontal linear lucency through the head of the fibula that represents a fracture of the styloid process [3].

  • Pearl: This injury may be confused with a Segond fracture, which is a small avulsion fracture fragment from the lateral tibial plateau associated with anterior cruciate ligament injury.

A proximal fibular avulsion fracture is commonly associated with injury to the posterior cruciate ligament, anterior cruciate ligament, popliteus, or meniscus. It is frequently seen with bone contusions and sometimes a tibial plateau fracture [2].

  • Pearl: Injury to the common peroneal nerve may occur as well. Remember to perform a thorough neurovascular examination [1].
  • Pearl: This fracture is a sign of posterolateral instability and likely internal derangement of the knee. Outpatient MRI can be used to evaluate the soft tissue components of the injury and diagnose associated injuries [2].

This injury indicates potential significant instability of the knee and requires outpatient follow-up with MRI. Operative management will be dictated on an individual basis, after evaluating MRI results. In the emergency department, place the patient in a knee immobilizer and recommend non-weight-bearing status until further imaging. Follow-up with orthopedics or sports medicine within 1 week.

  • Pearl: As always, perform a thorough neurovascular examination and consult orthopedics immediately if there is evidence of compromise. If your exam demonstrates significant instability and you are concerned about a spontaneously-reduced knee dislocation, consider ankle-brachial indices and/or further vessel imaging.

If diagnosis of this injury is delayed, posterolateral instability may develop. If not recognized and managed appropriately, this may hinder the success of a cruciate ligament reconstruction [1].

 

References and Resources:

Want more information about the knee exam? Check out the SplintER archives.

  1. Shon OJ, Park JW, Kim BJ. Current concepts of posterolateral corner injuries of the knee. Knee Surg Relat Res. 2017;29(4):256-268. PMID: 29172386
  2. Juhng SK, Lee JK, Choi SS, Yoon KH, Roh BS, Won JJ. MR evaluation of the “arcuate” sign of posterolateral knee instability. Am J Roentgenol. 2002;178(3):583-588. PMID: 11856678
  3. Strub WM. The arcuate sign. Radiology. 2007; 244(2):620-621. PMID: 17641383

By |2020-10-15T11:28:02-07:00Oct 14, 2020|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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SAEM Clinical Image Series: Red, White, & Blue

bite

A 29-year-old female presented to the emergency department for a rash on her right calf. 5 days prior, at her home in Alabama, the patient developed pain and swelling of her right calf following a spider bite while putting on her pants. The patient felt a “burning pain” and found a spider which she then killed. She went to a hospital and received cephalexin, trimethoprim/sulfamethoxazole, and oxycodone. Despite taking these medications she continued having aching pain rated 10/10 in her right calf along with generalized pruritus. The patient stated that the bite evolved from an initial generalized redness into a blue/black lesion with blistering and extensive redness along her leg and torso. She denied fever, chills, lightheadedness, abdominal pain, nausea, vomiting, and hematuria.

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By |2020-10-13T21:07:28-07:00Oct 12, 2020|Dermatology, Emergency Medicine, Environmental, SAEM Clinical Images, Tox & Medications|
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SplintER Series: A Pain in the Elbow

Little League Elbow

A 12-year-old male pitcher for a traveling club baseball team complains of acute worsening of right elbow pain that has been bothering him for 3 months. The radiograph is shown below (Frontal elbow view. Case courtesy of Dr. Levente István Lánczi, Radiopaedia.org, rID: 46853). What is your diagnosis? What causes this injury? What patient demographic is most susceptible to this injury? How can this injury be prevented? What is the management of this injury in the Emergency Department?

 

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By |2020-09-17T14:17:11-07:00Oct 7, 2020|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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Is it a Pneumothorax? An Unusual Post-Thoracentesis Radiograph

 

A 51-year-old female with a history of metastatic ovarian cancer on chemotherapy, malignant pleural effusions requiring repeat thoracentesis, and pulmonary embolism presented to the Emergency Department with worsening shortness of breath and dry cough. Upon arrival, she was hypoxic with an oxygen saturation level of 75% on room air. She was tachycardic, tachypneic, and her blood pressure was 125/56 mmHg. Labs revealed only a mild anemia (Hgb: 10.2). It was determined that her symptoms were secondary to recurrent right-sided malignant pleural effusions. Her presenting chest X-ray is pictured above (Image 1: Author’s own image).

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By |2020-09-08T16:16:43-07:00Sep 30, 2020|Pulmonary|
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SAEM Clinical Image Series: Man vs Pneumatic Nail Gun

A 40-year-old male presents with injury to his left hand by a nail gun. While at work, the patient accidentally shot himself with a nail gun. The nail went through pneumatic air hose tubing, his third finger, and his thumb, keeping them all connected. He immediately felt uncomfortable in his left arm, and, upon arrival to the emergency department (ED), complained of swelling in his left arm extending to his neck. He feels shortness of breath and “fullness” in his throat.

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By |2020-09-28T16:36:16-07:00Sep 28, 2020|Emergency Medicine, SAEM Clinical Images, Trauma|
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SAEM Clinical Image Series: Worsening Sore Throat

Computed tomography neck

A 40-year-old  male presented to the emergency department (ED) complaining of a sore throat for one week. The patient had presented ten days earlier following a stab wound to the anterior neck that violated the platysma. There was no vascular injury noted on the computed tomography angiography (CTA) but there was extensive soft tissue damage with emphysema extending into the retropharyngeal space. The patient underwent a flexible laryngoscopy by ENT, which showed no airway injury. He was observed in the intensive care unit for two days, then discharged. Following discharge, the patient had progressive sore throat and odynophagia, so he re-presented to the ED.

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By |2020-09-28T16:40:11-07:00Sep 28, 2020|Emergency Medicine, ENT, SAEM Clinical Images|
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