Quiz 101, February 5th, 2021

Welcome to the 101th FOAMed Quiz.

Sophie, Nicole, Joep, Denise, Gijs and Rick


Source image: www.emottowablog.com

Question 1

Achilles tendon ruptures are common in the ED. Whenever a conservative approach is chosen, patients receive a plaster cast. A walking boot may be a good alternative to casting, as patients can mobilize a lot sooner.

This recently published paper is about plaster cast versus walking boot for non-surgical treatment of achilles tendon rupture.

540 participants were randomised to receive plaster cast (n=266) or a functional brace (n=274). The primary outcome was patient-reported achilles tendon total rupture score (ATRS) at 9 months. This score consists of 10 questions about the function of the injured leg.

What did the authors find?

A: Plaster cast was superior to a functional brace at 9 months after randomisation

B: A functional brace was superior to plaster cast at 9 months after randomisation

C: Traditional plaster casting was not superior to early weight-bearing in a functional brace

The correct answer is C

EM Ottawa discussed this well conducted trial last week.

There was no difference in ATRS at 9 months post injury. There was also no difference in the rate of re-rupture of the tendon (17 [6%] of 266 in the plaster cast group vs 13 [5%] of 274 in the functional brace group).

Keep in mind blinding was not possible in this trial.

This just might be very good news for future achilles tendon rupture patients. Treatment with a walking boot allows these patients to mobilise straight away, without a cast for 8 weeks.

Source image: www.pixabay.com

Question 2

Which of the following is NOT part of the terrible triad of the elbow?

A: Fracture of the olecranon

B: Fracture of the coronoid process

C: Fracture of the radial head

D: Elbow dislocation

The correct answer is A

EMdocs covered elbow dislocations last week.

The classic terrible triad of the elbow consists of:
– Elbow dislocation
– Fracture of the coronoid process
– Fracture of the radial head

These devastating injuries need ORIF or replacement of radial head, ORIF of the coronoid, Lateral Collateral Ligament (LCL) reconstruction, and possible MCL reconstruction.

Source image: www.nuemblog.com

Question 3

Your 4-year old male patient presents with an unexplained fever for 6 days. You want to distinguish benign causes of fever and Kawasaki disease.

Which of the following clinical manifestations is most often present in patients with Kawasaki disease?

A: Adenopathy

B: Conjunctivitis

C: Strawberry tongue

D: Erythema on hand and feet

The correct answer is C

NUEM covered Kawasaki disease this week.

Kawasaki disease is a vasculitis of medium and small vessels. It is most often seen in children between 6 months and 5 years old.

Oral mucous membrane laesions are the most common clinical finding in Kawasaki disease, They are seen in approximately 90 percent of cases.

Treatment with IVIG within the first 10 days of illness has been shown to reduce the prevalence of the most feared complication: coronary artery aneurysms.

Source image: Case courtesy of Dr Chris O’Donnell, Radiopaedia.org, rID: 50812

Question 4

 Your 76 year old patient has unilateral headache for a couple of days. His Erythrocyte sedimentation Rate turns out to be 90 mm/hr.

Ultrasound may help you diagnose the patient’s condition. Which of the following is the most typical for giant cell arteritis (GCA)?

A: Stenosis of the temporal artery

B: Wall thickening (halo sign)

C: Cobblestones (cellulitis) of the adjacent subcutaneous tissue

D: Temporal artery dissection

The correct answer is B

This week the role of ultrasound in giant cell arteritis was discussed on Journal Feed.

The inflammatory infiltrate and edema of the tunica media leads to a hypoechoic, thickened rim of the vascular wall. This is called a halo sign. The compression sign is a permanent visible vessel wall during compression with the ultrasound probe. Both stenosis and complete vessel occlusion can also be seen in GCA, but are non specific. Cellulitis is not typically seen in GCA. Temporal artery dissections in GCA are very rare.

The sensitivity of ultrasound for GCA is thought to be about 85%.

Source image: www.pixabay.com

Question 5

Traumatic head injury in children is a common emergency department presentation. Every hospital uses protocols to choose whether or not to make a CT scan. Often children with coagulation diseases, such as haemophilia or Von Willebrand disease, are excluded from these protocols. CT is routinely performed by many practitioners in children with bleeding disorders who sustain a minor head injury.

The Bubble Wrap discussed a paper from Australia and New Zealand that looked at 20,137 children (<18 years) who presented to an emergency department after a traumatic head injury. In this group, 103 children had a bleeding disease.

 What did the researchers find?

A: The rate of CT scans was not more frequent in the group of children with a bleeding disease compared to children without a bleeding disease

B: There was a high incidence of intracranial hematomas in the group of children with bleeding disease receiving CT imaging

C: In the patients who underwent a CT, the trauma mechanism was milder in the group with a coagulation disorder compared to children without a bleeding disease

The correct answer is C

Dont forget the Bubble covered this paper last week.

In this study, only 1 of 103 children with a bleeding disorder had an intracranial hematoma requiring neurosurgical intervention. The rate of CT scans in children with bleeding disorders was significantly higher compared with children without bleeding disorders.

A more selective approach to CT decision-making is suggested by the authors. This might combine the severity of injury mechanism, a period of clinical observation and the type of underlying bleeding disorder.


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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen