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Background: Straight antegrade intramedullary nailing of proximal humerus fractures has shown promising clinical results. However, up to 36% of all humeri seem to be "critical types" in terms of the potential violation of the supraspinatus (SSP) tendon footprint by the nail's insertion zone. The aims of this study were to evaluate if a computed tomography (CT) scan could reliably predict the nail's entry point on the humeral head and if it would be possible to preoperatively estimate the individual risk of iatrogenic violation of the SSP tendon footprint by evaluating the uninjured contralateral humerus., Methods: Twenty matched pairs of human cadaveric shoulders underwent CT scans, and the entry point for an antegrade nail as well as measurements regarding critical distances between the entry point and the rotator cuff were determined. Next, gross anatomic measurements of the same data were performed and compared. Furthermore, specimens were reviewed for critical types., Results: Overall, 42.5% of all specimens were found to be critical types. The CT measurements exhibited excellent intra-rater and inter-rater reliability (intraclass correlation coefficients >0.90). Similarly, excellent agreement between the CT scan and gross anatomic measurements in contralateral shoulders (intraclass correlation coefficients >0.88) was found., Conclusion: Assessing the uninjured contralateral side, CT can reliably predict the entry point in antegrade humeral nailing and preoperatively identify critical types of humeral heads at risk of iatrogenic implantation damage to the SSP tendon footprint. This study may help surgeons in the decision-making processon which surgical technique should be used without putting the patient at risk for iatrogenic, implant-related damage to the rotator cuff., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

A prospective study was conducted in the emergency departments of two community hospitals to assess the accuracy of Doppler ultrasonography performed by emergency physicians in the evaluation of patients with symptoms suggestive of deep-vein thrombosis. Seventy-eight extremities in 76 patients were evaluated by both Doppler ultrasonography and contrast venography. Thirty-six Doppler examinations were normal, 26 were abnormal, and 15 were equivocal. Of the unequivocal examinations, three were false-negative and nine were false-positive. These data represent a sensitivity of 85%, specificity of 79%, negative predictive value of 92%, and positive predictive value of 65%. Negative predictive value improved to 100% among a subgroup of low-risk patients, and positive predictive value improved to 80% among a subgroup of high-risk patients. Our study suggests that Doppler ultrasonography is highly predictive of a negative venogram, particularly in the low-risk patient. Further study with a larger population is needed. The availability and noninvasiveness of Doppler ultrasonography make it a useful adjunct in the evaluation of suspected deep-vein thrombosis in the ED.

Extensive laboratory testing is often performed in the emergency department evaluation of the new-onset seizure patient. To determine the utility of such testing, a prospective study of patients with a new-onset seizure presenting to the ED of an inner-city, university-affiliated teaching hospital was done. One hundred thirty-six patients were entered into the study between October 1984 and January 1988. All patients had uniform data collection performed. Pertinent historical information and physical examination findings were recorded on a standardized form before laboratory abnormality was a sole or contributory cause of the seizure disorder. These included four patients with hypoglycemia, four with hyperglycemia, two with hypocalcemia, and one with hypomagnesemia. Only two cases (hypoglycemia) were not suspected on the basis of findings on the history or physical examination. In ED patients, the incidence of a new-onset seizure due to a correctable metabolic disturbance is low. We conclude that, with the exception of the serum glucose, the extensive ED laboratory workup often done for the evaluation of a new-onset seizure is unnecessary. Further test ordering should be directed by the medical history and physical examination.

Trauma resulting from motor vehicle crashes (MVCs) is the leading cause of death in persons 1 to 38 years old. The following prospective study was undertaken to assess the effect of safety belts on the types of injuries sustained in MVCs. A total of 1,364 patients from four Chicago-area hospitals were evaluated prospectively during a six-month period. Safety belts reduced the incidence of head, facial, thoracic, abdominal, and extremity injuries sustained in MVCs. Spinal injuries comprised the only group in which safety belt wearers sustained injuries more frequently than safety belt nonwearers. Further research on the different safety belt designs and effects of air bags is needed to reduce the incidence of cervical and lumbar strain in restrained patients.

It is apparent from this discussion that it may be exceedingly difficult to make the diagnosis of Boerhaave's syndrome. The failure to correctly diagnose this patient was due, in part, to the absence of vomiting in the history. Nevertheless, the presence of pneumomediastinum on the initial chest roentgenogram was a significant finding that was missed and would have suggested this diagnosis. This patient is an example of an "atypical" presentation and demonstrates that vomiting need not be a part of the presentation. Because esophageal rupture is a rare clinical entity, a high index of suspicion and careful examination of the chest roentgenogram are mandatory to establish the correct diagnosis.

Clostridial infections, particularly myonecrosis, can be fulminant and fatal; they often arise without an obvious history of trauma. The cardinal diagnostic clues (Figure 3) must be recognized so that specific therapy can be initiated promptly and mortality can be minimized. Aggressive medical care, including crystalloid fluid therapy and antibiotics, must be initiated quickly. Vasopressors should be avoided. Antitoxin has no role in contemporary care. Early hyperbaric oxygenation is beneficial, but it should be preceded by decompressive fasciotomy if limb edema is marked. Otherwise, definitive debridement or amputation is best delayed until after hyperbaric therapy is begun. Regionalization of care and long transport times also must be considered seriously in determining the therapeutic approach.

In many institutions it is the "standard of care" to obtain serum chemistries and anticonvulsant levels as part of the emergency department evaluation of seizure patients. To determine the efficacy of such a workup in the ED, 163 seizure patients presenting to an inner-city teaching hospital were studied in a standardized, prospective manner. After the clinical examination all patients had CBC, serum electrolyte, BUN, creatinine, glucose, calcium, magnesium, and if indicated, anticonvulsant drug level determinations performed. Any patient presenting with a first-time seizure (in patients greater than 6 years old), recent head trauma, focal neurologic deficit, or focal seizure activity had cranial computerized tomography (CCT). After obtaining historical and physical examination and before receiving laboratory results, as many as five likely etiologies were listed and assigned probability ratings. After review of the laboratory data (and CCT scan, if obtained), final etiologies again were listed and assigned percentages of likelihood. Significant abnormalities (ie, those that changed diagnosis, management, or disposition) were found in 104 patients; 96 had subtherapeutic anticonvulsant levels, five had abnormal CCT scans, two had hypoglycemia, and one had hyperglycemia as the cause of seizure. The clinical examination successfully predicted those abnormalities in all but two cases (one each of hyperglycemia and subdural hematoma). We contend tha routine serum chemistries in patients presenting to the ED are of extremely low yield, and that the clinical examination can predict accurately the need to obtain these studies. CCT scanning is useful in selected patients, and was found to be abnormal in five of 19 (25%) patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Carbon monoxide (CO) is the leading toxic cause of death in the United States today. Unsuspected exposure to this gas will sometimes result in clinically significant, but undiagnosed, toxicity. A high incidence of such unsuspected exposures would make screening for these worthwhile among high-risk populations. We conducted a two-part study to determine the value of screening for unsuspected CO exposure in a population of patients presenting to an emergency department. The first part of our study involved the prospective screening of ED patients using CO breath analysis, regardless of their chief complaint. In the second part, COHGB levels of all patients who underwent arterial blood gas analysis during the study period were reviewed retrospectively. Of 1,038 patients screened by this combined approach, only 29 (2.8%) had abnormal CO breath readings and/or COHGB levels. Of a condensed subgroup of 152 patients defined retrospectively by chief complaint, eight (5.3%) had abnormal values. We conclude that routine screening of ED patients for unsuspected CO exposure is not practical. Although yield increases when patients are screened in a more selective manner on the basis of chief complaint, such an increase still does not appear to justify the screening process.