Richard B. Birrer

Managing ankle injuries in the emergency department

We review the anatomy and physiology of the ankle joint with attention to the structures most likely to be injured. We discuss the epidemiology of ankle injuries and their physical and radiographic evaluation, including the Ottawa Ankle Rules. Treatment, consultation, and pitfalls are followed by more specific discussions of tendonitis, Achilles tendon injury, tendonous subluxations, tarsal tunnel syndrome, sonovial impingement, and injury to the os trigonum. The references provide a guide for further reading.

Orbital emphysema: How common, how significant?*

STUDY OBJECTIVEnTo describe the natural history of orbital emphysema and its management in the emergency setting.nnnDESIGNnRetrospective medical record review.nnnSETTINGnInner-city integrated hospital system (four divisions) including one Level I trauma center.nnnPARTICIPANTSnAll cases of orbital floor fracture and orbital emphysema from January 1, 1988, to December 31, 1993.nnnRESULTSnThe average patient was aged 33 years, and the male-to-female ratio was 7 to 1. Trauma was the underlying etiology in all patients. Seventy-four percent of patients required hospitalization, and 43% developed significant complications. Eighty-three percent were managed with antibiotics. Orbital emphysema was identified on conventional radiographs in 65% of cases.nnnCONCLUSIONnIdentification of orbital emphysema in the ED should prompt a careful search for associated injury. Consultation should be sought in the presence of orbital or ocular injury. Antibiotic prophylaxis is not necessary for clean wounds.

Lyme carditis: A rare presentation in an unexpected setting

A case is reported of a 27-year-old man who presented to an inner city trauma center after he had experienced several seizure-like episodes. He was diagnosed with Lyme carditis and required 6 weeks of treatment with intravenous ceftriaxone for complete resolution of his symptoms. The case is discussed along with a review of the literature.

SELF-MUTILATION: THREE CASES AND A REVIEW OF THE LITERATURE

The self-mutilating patient is an unusual psychiatric presentation in the emergency department (ED). Nonetheless, serious underlying psychiatric pathology and drug abuse are important background risk factors. A careful stepwise approach in the ED is essential, although the prognosis, follow-up, and eventual rehabilitation are poor.

Obese Children Should Be Screened for Hypercholesterolemia

Screening only those with a positive family history misses many children with hypercholesterolemia. This study investigated whether sensitivity improved by adding obesity as a criterion when screening children for cholesterol. During a two-year period screenings were conducted on 506 inner-city subjects aged 5-19. Demographic, clinical, and dietary information was also recorded. Mean age of participants was 11 ± 4 years; 52 percent were female, 53 percent black, 39 percent Hispanic, and 8 percent other. Mean cholesterol level was 4.14 mmol/l (160 mg/dl). In multivariate analysis obesity was an independent risk factor for hypercholesterolemia, F = 23.14, p < 0.001. The sensitivity of obesity as a screening tool for hypercholesterolemia was better than that for positive family history (42 vs. 24 percent, respectively). Combining the two improved the sensitivity to 49 percent. The authors recommend expanding the indications for screening children to include obesity, in addition to positive family history of hypercholesterolemia or premature cardiovascular disease.

Vaginal bleeding secondary to an aborting uterine leiomyoma.

The authors present the case of a young woman who presented to the emergency department with vaginal bleeding and an aborting uterine leiomyoma. Although well described in the gynecologic literature, this phenomenon is not commonly seen in the emergency department, nor is it well described in the emergency medicine literature. The case highlights the importance of a thorough pelvic examination in all women presenting with a complaint of vaginal bleeding, and in addition it describes an atypical presentation for uterine leiomyomas.

A DESCRIPTIVE ANALYSIS OF EMERGENCY VISITS TO AN INNER CITY FAMILY PRACTICE CENTER

A six-month prospective study of daily emergency visits was performed at an inner city family practice center in order to understand the utilization pattern of emergency services. 487 visits were identified during the study period. In general, patients of junior residents made more visits. The majority of visits (97%) were nonemergent. The most common presenting complaint was a general symptom (17%), although the most frequent diagnosis was in the supplementary category (17%) that includes medication renewals, the completion of forms and maternal and child health care. Females, the unemployed, the elderly, and individuals with poverty levels of income were most frequently seen in the emergency setting. The reasons for these patterns and the need for further investigations in this area are discussed.

Selected Disorders of the Cardiovascular System

Endocarditis is infection of the heart valves. Microorganisms (i.e., bacteria, fungi, protozoa) attack the valves of the heart and may cause scarring and subsequent stenosis or insufficiency of the valve. Untreated, the disease can lead to acute valvular incompetence, bacteremia, fulminant sepsis, and death. Endocarditis is classified into subacute or acute forms.

The Urban Environment and Its Impact on Primary Care

There are several problems in the teaching and practice of primary care in the urban sector.12 First, the concept of urban is evasive and continuously evolving. A technical definition related to cultural, national, political, historical, demographic, or geographic criteria does not provide the latitude or scope for dealing with health care needs and delivery systems. Second, the traditional well-known components characteristic of the nuclear family in the rural sector often do not exist in the urban setting but rather are replaced by a wide spectrum of poorly defined alternative family styles. Third, the socioeconomic, cultural, and ethnic diversity of urban living groups, as well as their mobility, create a unique, challenging, and difficult population for physicians to provide continuous, comprehensive, coordinated care.3 This paper will briefly discuss each of these elements and their rele-