Michael D. Burg

An obscure cause of hip pain.

BACKGROUND We describe the case of a 53-year-old woman with hip pain secondary to an obturator hernia. Obturator hernia is uncommon, and the most lethal of all abdominal hernias. The high mortality rate of this disease requires an acute clinical awareness to facilitate rapid diagnosis and surgical intervention for improved prognosis. OBJECTIVES This case highlights a vitally important diagnosis that is rarely discussed in the emergency medicine literature. CASE REPORT Our patient presented without symptoms typical of a bowel obstruction, although a computed tomography scan of her pelvis revealed an incarcerated obturator hernia and a small bowel obstruction. CONCLUSIONS Early diagnosis and expeditious surgical management resulted in a good outcome.

An Unusual Case of Otorrhagia

A 64-year-old man presented to the Emergency Department complaining of headache and bilateral ear pain after falling face first during a syncopal episode. He denied nausea, vomiting, or focal neurological complaints, and was alert and oriented, with blood-tinged fluid—which formed ‘‘halos’’ on the bed sheets—draining from both ears. A brain computed tomography (CT) scan with axial and coronal views was performed due to a concern for basilar skull fracture and was read as negative by the on-duty radiologist (Figure 1). However, review of the study by the emergency physicians/case authors demonstrated bilateral comminuted fractures and dislocations of the mandibular condyles (Figure 2). The patient was admitted to the Oromaxillofacial Surgery service for repair of his injuries and was discharged the following morning. No basilar skull fracture was identified. The patient was well at 30-day follow-up.

Sports Medicine for the Emergency Physician: A Practical Handbook. Edited by Anna L. Waterbrook, MD, FACEP, CAQ-SM. New York: Cambridge University Press, 2016; 427 + ix pp;

I love bullets. Just to be clear, not the projectile type but the type that appears in writing to highlight a list or emphasize a point. For me, text with bullets is like prose light, all the content without all the literary calories and extras. It seems like a very efficient way to present learning material—focused, pure, high yield. If you’re fond of bullets as well, then you’ll really appreciate the book Sports Medicine for the Emergency Physician: A Practical Handbook. Its text contains nothing but useful bulleted points. Sports Medicine for the Emergency Physician is ably edited by EM residency–trained and sports medicine fellowship– trained Associate Professor Anna L. Waterbrook, MD. The book’s opening page indicates that it is “the only resource of its kind,” “Written by sports-trained emergency physicians . . . ” and “Created specifically for the emergency medicine provider . . . ” Doctor Waterbrook’s introduction adds that her book is “not meant to be . . . comprehensive. Rather it is focused “on the emergent and common conditions seen in the ED.” The table of contents lists chapters on shoulder, elbow, wrist, hand, pelvis/hip/thigh, knee, lower leg/ ankle, foot, cervical spine, lumbar spine, concussion, arrhythmias/cardiac arrest, exertional heat illness, and splinting. During my review I couldn’t think of any major topic that was omitted. Most of the chapters follow a somewhat scripted format with individual variations suited to the topics under discussion. Key chapter sections include background/epidemiology, anatomic considerations/pathophysiology, focused history and physical exam, and differential diagnosis– emergent and common diagnoses. Pearls and pitfalls are liberally sprinkled throughout the chapters, as are truly excellent graphics of nearly every description: black and white and color photos, tables, charts, diagrams, and so forth. The prose bullets make their points well. The images do the same. Taken together, the text and image combination really drives home the myriad teaching points. Again, I couldn’t find any major (or even minor) omission. It’s all there—general description of the entity under discussion, mechanism of injury, presentation, physical examination, essential diagnostics, ED treatment, disposition, complications, pediatric considerations, and—as mentioned—pearls and pitfalls. Each chapter closes with an extensive and current recommended reading and reference list. If I had one wish for this book, it would be to always question and eschew medical dogma and tradition. I didn’t really find (or search diligently for) too many examples of “old school” dictates but the shoulder chapter contains the statement “X-rays are always indicated when a dislocation is suspected.” There’s definitely current medical literature to support a different approach, and I think many of us would not x-ray the chronic “dislocator” who presents after having rolled over in bed. However, I’ll admit that this is a little nit-picky on my part, a few drops of quibble-able content in a veritable ocean of great material. Try as I might I can offer no other suggestions for improvement or change in this book. Temple Grandin has opined that “People are always looking for the single magic bullet that will totally change everything. There is no single magic bullet.” (Besides, I can’t resist one more bullet-related comment because I was so taken with this book’s approach and structure). However, in my humble opinion, all the bullets taken together from Sports Medicine for the Emergency Physician will absolutely transform your practice. Bottom line—buy this book that’s chock full of excellent teaching points. It’s ideally suited to the EM provider who sees athletes or athlete wannabes or even those who simply injure themselves in ways that an athlete might, and that’s pretty much all of us.