why this blog?

Likelihood Ratio (LR) in Emergency Medicine


Diagnosis of scaphoid fractures.
 Are plain radiographs reliable?

Clinical Scenario

It’s a busy wednesday morning in ED. 
A 18 yo guy presents with the right hand upraised and dressed. 
In the other hand he has a bundle of X ray.   
“About ten days ago, it was a Saturday night, I was with my new girl-friend. Hitting a punch bag as hard as possible I felt pain to my right wrist. My doctor ordered wrist X ray. It’s not broken, he says, but I’m very afraid, when I move the wrist  it pains me so much”.
On clinical examination there is snuff box tenderness, the axial loading maneuvre on the thumb is positive (see previous post). 
The emergency phisician takes an accurately look at the X rays. They are of high quality, the study had 4 views of the scaphoid, there’s no evidence of irregularity of cortex, the scaphoid fat pad seems normal.
“Repeat X-ray” orders the doctor….


Pretest probability of scaphoid fracture, in a  guy with tipical history and snuff box tenderness (see the previous post) with initial negative X-Ray, is about 25% . 
The fat pad sign has a poor value (if you don’t know it click here), on the other hand a 10-14 day follow up X rays is a good idea but is not sufficiently accurate, post test probability doesn’t change even if a second X ray resultes negative.  

And now? Bone scan, US, CT or RMN?

To be continued……


CR Carpenter
Adult scaphoid fracture
Acad Emerg med 2014 21:102-121 

CA Germann
Risk management and avoiding legal pitfalls in the emergency treatment of high-risk orthopedic Injuries
Emerg Med Clin N Am 2010 28: 969-996 

Ciro Paolillo



Is a cold steak enough in black eye?

Clinical Scenario

A young guy comes to the ED after a car crash. While he was driving, the car in front of him stopped abruptly so they crashed. Fortunately speed was low and he does not report major trauma, but a black eye due to an impact towards the airbag. You promptly evaluate his sight and find no deficit, no diplopia, palpation does not show fracture steps or enphysema, skin sensation is preserved.

It’s nothing, just put a cold steak on it!

Would you really say this?



Is my hand broken?

Clinical Scenario

A 24 y/o guy presents in ED with the left hand upraised. 
“I fell off my bike yesterday – he says – I remember a serious impact with an outstreched palm.”
There aren’t wounds, he feels pain on the radial side of  left wrist, there is an anatomical snuffbox tenderness. The clamp sign is positive, but the resisted pronation maneuvre and the longitudinal compression test are negative.  

Is it broken? Asks worried the guy.



Ottawa ankle rules. 
Does it really work?

Clinical Scenario

A 16 yo guy is brought in ED by his mother after a scholar accident.
While he was running, he crashed. 
My son has a sore ankle!  Is it broken? Asks the mother seriously worried.  
The ankle his slightly tumefied, there isn’t bone tenderness at the posterior edge or tips of either malleolus, neither there is pain during the pressure of the navicular bone or the base of the fifth metatarsal. 
Are you able to take 4 steps? - asks the doctor.



Does every shoulder pain means magnetic risonance?

Clinical Scenario

A 35 y/o male come to the ED because of pain in his right shoulder, he refers the pain started some month ago during a tennis match, the pain continued but it wasn't so high so he kept playing in the last months, now it is worse. "My tennis mate told me I should perform a magnetic resonance, because it might be a rotator cuff disease" (RCD).
You listen to the patient but decide first to act as a physician and make the old and fascinating physical examination...
What you find is a normal movement of the shoulder, no pain in abducting the arm (arch test), no weakness or pain in internal and external rotation. (see video)

And so what?



Alarm symptoms and gastric cancer. Are they alarms or they are alarming?

Clinical Scenario

It’s a busy Monday morning in ED. 
A doctor at the phone – calls the nurse – there’s a primary care physician. 
Hi – says a voice on the other side –  I’m in a patient’s home. 
He’s a 40 yo man with dyspepsia, his wife refers weight loss of about 10 Kg in the last three months. He is pale, but not tachicardic, abdomen is treatable, on rectal examination I find normal stool. 

I’m warried he probably has a gastric cancer, Is it possible to schedule an urgent gastroscopy for this morning?



Age of 45 and dyspepsia.

Clinical Scenario

It’s the begining of another night shift in ED. Rik, an agreable young colleague approximates: Hi- he says – I have just seen a 60 y/o man who refers epigastric pain since 2 days. He denies bleeding and weight loss, he isn’t anemic. The bedside US shows a normal gallbladder and a normal abdominal aorta, ECG is OK. It seems an uncomplicated dyspepsia, but he is a 60y/o, I’m worried about a grastric cancer.