338 Emergency Medicine
(a)Ice may decrease swelling but will not prevent compartment syndrome.
There is also a risk of decreasing blood flow to the damaged tissue because of the
vasoconstrictive effect of the ice. (b)There is no reason to suspect that an occult
fracture is causing the pain. (c)Elevation to the level of the heart is recom-
mended, however, all constrictive bandages should be removed. Elevation
above the heart is not recommended. Again, this can limit blood flow to the
damaged tissue. (d)A DVT should not cause this pain.
305.The answer is d.(Rosen, pp 596-597.)The patient’s clinical presen-
tation is consistent with a posterior shoulder dislocation.Posterior dislo-
cations are rare and account for only 2% of all glenohumeral dislocations.
Posterior dislocations are traditionally associated with seizure patients
and lightening injuries.However, the most common dislocation seen in
postseizure patients is an anterior dislocation. Classically, the patient holds
the dislocated arm across the chest in adduction and internal rotation.
Abduction is limited and external rotation is blocked. Radiographs may
reveal a “light bulb” sign, which is the light bulb appearance when the
humeral head is profiled in internal rotation.
Although any type of injury can occur with a seizure, the patient’s clin-
ical presentation is consistent with a posterior shoulder dislocation.
306.The answer is b.(Rosen, pp 538-539.)Thescaphoidis the most
commonly fractured carpal bone. It is typically seen in patients in their
twenties to thirties after a FOOSH. Classically, physical examination
reveals tenderness in the anatomic snuffbox,the space between the
extensor pollicis longus and the extensor pollicis brevis. On radiography,
however, up to 15% of scaphoid fractures are not detected. As the necrotic
bone at the fracture site is resorbed, the fracture line often becomes appar-
ent on radiographs at 10 to 14 days after injury. Therefore, patients with
snuffbox tenderness and an initial radiograph should be splinted in a
thumb spica splintand asked to return for repeat radiographs in 10 to
14 days.
(a)Placing an elastic wrap will not provide adequate immobilization
and will lead to increased complications if a fracture is present. (c)Ice is
recommended but immobilization is also required. (d)Even a CT scan will
not pick up the fracture immediately after injury. However, if there is snuff-
box tenderness after 14 days and the radiograph remains negative, a CT
scan is warranted. (e)This is unnecessary because it is not clear if the
scaphoid is fractured.