{"id":1374,"date":"2017-04-05T12:17:13","date_gmt":"2017-04-05T16:17:13","guid":{"rendered":"https:\/\/www.roshreview.com\/?p=1374"},"modified":"2017-04-05T12:17:13","modified_gmt":"2017-04-05T16:17:13","slug":"ep-21-galeazzi-fractures-malnutrition-chest-tubes-central-retinal-artery-occlusion-boutonniere-deformity-anticonvulsant-hypersensitivity-syndrome","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/ep-21-galeazzi-fractures-malnutrition-chest-tubes-central-retinal-artery-occlusion-boutonniere-deformity-anticonvulsant-hypersensitivity-syndrome\/","title":{"rendered":"Podcast Ep 21: Galeazzi Fractures, Malnutrition, &amp; More"},"content":{"rendered":"\n<figure class=\"wp-block-audio\"><audio controls src=\"https:\/\/media.blubrry.com\/thereveal\/s\/media.blubrry.com\/roshcast\/s\/content.blubrry.com\/roshcast\/Ep_21_Roshcast_Emergency_Board_Review.mp3\"><\/audio><\/figure>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\"><p><span>Change your thoughts and you change your world.<\/span><\/p><cite>-Norman Vincent Peale<\/cite><\/blockquote>\n\n\n\n<h6 class=\"wp-block-heading\">Welcome back to Episode 21! We are all over the place this week, tackling topics from orthopedics to electrolyte abnormalities. Thanks to our listeners for the excellent feedback. Keep it coming to&nbsp;<a href=\"mailto:roshcast@roshreview.com\">roshcast@roshreview.com<\/a>. Let&#8217;s get started with a quick neurology rapid review from prior episodes!<\/h6>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"201\" height=\"74\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview-2-e1475624722961.png\" alt=\"\" class=\"wp-image-818\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li>Treatment for a&nbsp;<strong>radial nerve palsy<\/strong>&nbsp;is supportive with a&nbsp;<strong>wrist splint<\/strong>, and the condition is typically&nbsp;<strong>self-limited<\/strong>.<\/li><li><strong>VP shunt obstruction<\/strong>&nbsp;occurs proximally more often than it occurs distally.&nbsp;<strong>Proximal VP shunt<\/strong>&nbsp;obstruction occurs due to&nbsp;<strong>choroid plexus obstruction<\/strong>&nbsp;or&nbsp;<strong>increased protein&nbsp;<\/strong>within the CSF.&nbsp;<strong>Distal VP<\/strong>&nbsp;shunt obstruction occurs due to&nbsp;<strong>abdominal pseudocyst<\/strong>&nbsp;formation, which typically presents with&nbsp;<strong>abdominal pain<\/strong>&nbsp;due to the&nbsp;<strong>large size of the cyst<\/strong>.<\/li><li><strong>Lyme disease<\/strong>&nbsp;is the most common cause of a&nbsp;<strong>bilateral Bell\u2019s palsy<\/strong>. &nbsp;Remember that a&nbsp;<strong>peripheral facial nerve palsy<\/strong>&nbsp;can be distinguished from a central one by involvement of the forehead.<\/li><\/ul>\n\n\n\n<p><strong>Now onto this week\u2019s podcast<\/strong><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 1<\/strong><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"142\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/X-ray-Galeazzi-fracture-300x142.jpg\" alt=\"\" class=\"wp-image-1385\" srcset=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/X-ray-Galeazzi-fracture-300x142.jpg 300w, https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/X-ray-Galeazzi-fracture.jpg 532w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/figure><\/div>\n\n\n\n<p>A patient presents to you as a transfer from an outside facility with the radiograph seen above. Which of the following exams will evaluate for the most commonly associated nerve injury in this type of fracture?<\/p>\n\n\n\n<p><span>A. Ability to make a \u201cthumbs up\u201d sign<\/span><\/p>\n\n\n\n<p><span>B. Ability to make an \u201cOK\u201d sign <\/span><\/p>\n\n\n\n<p><span>C. Sensation to the index finger <\/span><\/p>\n\n\n\n<p><span>D. Sensation to the little finger<\/span><\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Image-Galeazzi-Fracture-Monteggia.png\" target=\"_blank\" rel=\"noopener noreferrer\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 2<\/strong><\/p>\n\n\n\n<p>Which of the following is a common cause of hypomagnesemia?<\/p>\n\n\n\n<p><span>A. Antacid use<\/span><\/p>\n\n\n\n<p><span>B. Hypoparathyroidism<\/span><\/p>\n\n\n\n<p><span>C. Hypothyroidism<\/span><\/p>\n\n\n\n<p><span>D. Malnutrition<\/span><\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Image-Hypomagnesemia-Magnesium.png\" target=\"_blank\" rel=\"noopener noreferrer\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 3<\/strong><\/p>\n\n\n\n<p>A 24-year-old man is brought to the ED after sustaining a stab wound to the right side of his chest. He is diagnosed with a hemothorax and a 38-French chest tube is placed in the resuscitation room. Which of the following best predicts the need for urgent thoracotomy?<\/p>\n\n\n\n<p><span>A. Initial chest tube output of greater than 1,000 mL of blood <\/span><\/p>\n\n\n\n<p><span>B. Initial chest tube output of greater than 10 mL\/kg of blood <\/span><\/p>\n\n\n\n<p><span>C. Persistent output of greater than 100 mL of blood per hour for the first 3 hours following chest tube placement <\/span><\/p>\n\n\n\n<p><span>D. Persistent output of greater than 7 mL of blood per kilogram per hour following chest tube placement<\/span><\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Image-Traumatic-Hemothorax-Exploratory-Thoracotomy.png\" target=\"_blank\" rel=\"noopener noreferrer\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 4<\/strong><\/p>\n\n\n\n<p>A 45-year-old woman with a history of hypertension and atrial fibrillation presents with a complaint of sudden onset vision loss in her right eye that occurred 10 minutes prior to arrival in the emergency department. She denies associated pain or trauma to the eye. Visual acuity is 20\/20 at baseline, however she can now only count fingers on the right. What is the appropriate next step?<\/p>\n\n\n\n<p><span>A. Arrange for 24-hour follow-up with ophthalmology<\/span><\/p>\n\n\n\n<p><span>B. Digitally massage the globe<\/span><\/p>\n\n\n\n<p><span>C. Obtain a CT scan of the head without contrast<\/span><\/p>\n\n\n\n<p><span>D. Perform an anterior chamber paracentesis<\/span><\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Image-Central-retinal-artery-occlusions-CRAO.png\" target=\"_blank\" rel=\"noopener noreferrer\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 5<\/strong><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"244\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Image-boutonniere-deformity-for-Question-300x244.png\" alt=\"\" class=\"wp-image-1390\" srcset=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Image-boutonniere-deformity-for-Question-300x244.png 300w, https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Image-boutonniere-deformity-for-Question.png 463w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/figure><\/div>\n\n\n\n<p>A 19-year-old man presents to the ED after jamming his finger while playing basketball. On exam, he has swelling and tenderness to the proximal interphalangeal joint and pain with proximal interphalangeal joint extension. An X-ray is negative for a fracture. To prevent the deformity seen in the above image from developing, what type of splint should be placed?<\/p>\n\n\n\n<p><span>A. Distal interphalangeal joint in extension, proximal interphalangeal joint and metacarpal phalangeal joint with full range of motion<\/span><\/p>\n\n\n\n<p><span>B. Distal interphalangeal joint, proximal interphalangeal joint, and metacarpal phalangeal joint in extension<\/span><\/p>\n\n\n\n<p><span>C. Proximal interphalangeal joint in extension, distal interphalangeal joint and metacarpal phalangeal joint with full range of motion<\/span><\/p>\n\n\n\n<p><span>D. Proximal interphalangeal joint in flexion, distal interphalangeal joint in extension, and metacarpal phalangeal joint with full range of motion<\/span><\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Image-Swan-Neck-Deformity-mallet-finger-boutonniere-deformity.jpg\" target=\"_blank\" rel=\"noopener noreferrer\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 6<\/strong><\/p>\n\n\n\n<p>Which of the following statements regarding anticonvulsant hypersensitivity syndrome is true?<\/p>\n\n\n\n<p><span>A. Cross-reactivity between anticonvulsants is rare<\/span><\/p>\n\n\n\n<p><span>B. Mucous membranes are spared early in the disease <\/span><\/p>\n\n\n\n<p><span>C. Onset usually occurs after longstanding therapy<\/span><\/p>\n\n\n\n<p><span>D. Rash is the most common initial symptom<\/span><\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Anticonvulsant-hypersensitivity-syndrome.jpg\" target=\"_blank\" rel=\"noopener noreferrer\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"201\" height=\"74\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview-2-e1475624722961.png\" alt=\"\" class=\"wp-image-818\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li>A <strong>Galeazzi fracture<\/strong> is a fracture of the <strong>middle to distal third of the radius<\/strong> with <strong>dislocation or subluxation of the distal radioulnar joint<\/strong>.<\/li><li>In <strong>Galeazzi fractures<\/strong>, the <strong>anterior interosseous nerve <\/strong>(or AIN) is at risk. Check its function by <strong>testing the flexor pollicis longus<\/strong> and the <strong>flexor digitorum profundus<\/strong> by asking the patient to make an \u201c<strong>OK\u201d sign<\/strong>.<\/li><li>Asking the patient to show you a \u201c<strong>thumbs up<\/strong>\u201d tests the <strong>radial nerve<\/strong>.<\/li><li>The <strong>ulnar nerve<\/strong> is innervated by the <strong>C8\u2013T1 <\/strong>spinal nerve roots.<\/li><li><strong>Hypomagnesemia<\/strong> can be seen in patients with <strong>chronic malnutrition<\/strong>, including <strong>alcoholics<\/strong>, children with <strong>restricted diets<\/strong>, and in the <strong>elderly<\/strong>. It is also seen in patients on <strong>diuretics<\/strong>, those taking <strong>aminoglycosides<\/strong>, and patients on a <strong>PPI<\/strong>. <strong>Concomitant hypokalemia<\/strong> is common.<\/li><li><strong>Hypomagnesemia<\/strong> typically presents with vague symptoms including <strong>muscle cramping<\/strong> and <strong>diffuse weakness<\/strong>. More serious complications include vertigo, ataxia, seizures, increased reflexes, and cardiac conduction abnormalities, such as atrial fibrillation, PVCs, and ventricular tachycardia.<\/li><li><strong>Indications for emergent thoracotomy<\/strong> in a patient with a <strong>traumatic hemothorax<\/strong> include: <ul><li>Initial chest tube drainage of over 20 ml\/kg of blood<\/li><li>&gt;3 mL\/kg\/hr of blood for 4 hours<\/li><li>Persistent bleeding of over 200 ml\/hour for 3 hours<\/li><li>Persistent bleeding of 7 ml\/kg\/hour<\/li><li>Refractory shock<\/li><li>Chest that remains more than half full of blood on chest X-ray despite tube insertion <\/li><\/ul><\/li><li><strong>Traumatic hemothorax<\/strong> is usually due to <strong>lung parenchymal injury<\/strong> which is usually self-limited. &nbsp;It may also be due to <strong>small or large vessel vascular injury<\/strong> or even <strong>cardiac injury<\/strong>.<\/li><li><strong>Central retinal artery occlusion (CRAO)<\/strong> <strong>risk factors<\/strong> include <strong>hypertension<\/strong>, <strong>atrial fibrillation<\/strong>, <strong>diabetes<\/strong>, valvular heart disease, arteriosclerosis, hyperlipidemia, sickle cell anemia, carotid artery disease, and vasculitis.<\/li><li><strong>CRAO<\/strong> typically presents with <strong>acute painless vision loss<\/strong> followed by the development of a <strong>Marcus-Gunn pupil<\/strong>. On exam, you would expect a <strong>pale retina<\/strong> and <strong>cherry red macula<\/strong>. &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;<\/li><li>Treatment for <strong>CRAO<\/strong> includes <strong>digital globe massage<\/strong> and medications like <strong>acetazolamide, mannitol, topical timolol, and sublingual nitro<\/strong>. More advanced measures include <strong>hyperbaric oxygen<\/strong> and <strong>anterior chamber paracentesis<\/strong>.<\/li><li>A <strong>boutonni\u00e8re <\/strong>deformity, which has <strong>PIP flexion and DIP extension<\/strong>, is most commonly caused by <strong>rheumatoid arthritis<\/strong>, but may also be caused by <strong>trauma<\/strong>. In the traumatic setting, it is typically caused by a <strong>central slip injury<\/strong>.<\/li><li>To treat presumed <strong>traumatic central slip injury<\/strong>, <strong>splint<\/strong> the patient in <strong>PIP extension<\/strong>, leaving the DIP and MCP in full ROM. If there is an <strong>associated fracture<\/strong>, <strong>internal surgical fixation<\/strong> may be required.<\/li><li><strong>Anticonvulsant hypersensitivity syndrome<\/strong>, now more broadly classified under <strong>DRESS<\/strong>, presents with <strong>a 1\u20132 week period<\/strong> of <strong>nonspecific symptoms<\/strong> followed by a <strong>diffuse erythematous rash<\/strong>. Severe cases are associated with <strong>fever<\/strong>, <strong>rash<\/strong>, and <strong>internal organ involvement<\/strong> and carry a 10% mortality. &nbsp;<\/li><li>Treatment for <strong>DRESS<\/strong> is with <strong>IV steroids and immunoglobulin<\/strong>, in addition to supportive care and cessation of the offending agent.<\/li><\/ul>\n\n\n\n<p>So that wraps up Episode 21. Remember&nbsp;to follow us on Twitter <a href=\"https:\/\/twitter.com\/roshcast\">@Roshcast<\/a>&nbsp;and check out the new <a href=\"https:\/\/www.roshreview.com\/tag\/teaching-image\/\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\">Teaching Image<\/a> series on the blog.<\/p>\n\n\n\n<p>Until next time,<br>Jeff and Nachi<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Welcome back to Episode 21! We are all over the place this week, tackling topics from orthopedics to electrolyte abnormalities. Thanks to our listeners for the excellent feedback. Keep it coming to roshcast@roshreview.com. Let&#8217;s get started with a quick neurology rapid review from prior episodes!<\/p>\n","protected":false},"author":11,"featured_media":1383,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[2025,1999],"tags":[2116,2135,2158,2168,2201,2285,2348,2350,2365,2368,2455,2501,2523,2534,2565,2666,2667,2694,2780,2829,2836,2843,2845,2994,3000,3002,3168,3199,3358,3440,3470,3580,3648,3677,3696],"coauthors":[],"class_list":["post-1374","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-emergency-medicine","category-podcast","tag-alcohol","tag-aminoglycosides","tag-anterior-interosseous-nerve","tag-anticonvulsant-hypersensitivity-syndrome","tag-atrial-fibrillation","tag-boutonniere","tag-central-retinal-artery-occlusion","tag-central-slip","tag-cherry-red-macula","tag-chest-tubes","tag-crao","tag-diabetes","tag-diuretics","tag-dress","tag-elderly","tag-flexor-digitorum-profundus","tag-flexor-pollicis-longus","tag-galeazzi","tag-hemothorax","tag-hyperbaric-oxygen","tag-hypertension","tag-hypokalemia","tag-hypomagnesemia","tag-magnesium","tag-malnutrition","tag-marcus-gunn-pupil","tag-orthopedics","tag-painless-vision-loss","tag-ppi","tag-rashes","tag-rheumatoid-arthritis","tag-steroids","tag-thoracotomy","tag-trauma","tag-ulnar-nerve"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v21.7 (Yoast SEO v26.6) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Podcast Ep 21: Galeazzi Fractures, Malnutrition &amp; More | RoshReview.com<\/title>\n<meta name=\"description\" content=\"Welcome to RoshCast (Ep. 21), the first question and answer style emergency medicine podcast. Listen and learn more.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.roshreview.com\/blog\/ep-21-galeazzi-fractures-malnutrition-chest-tubes-central-retinal-artery-occlusion-boutonniere-deformity-anticonvulsant-hypersensitivity-syndrome\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Podcast Ep 21: Galeazzi Fractures, Malnutrition, &amp; More\" \/>\n<meta property=\"og:description\" content=\"Welcome to RoshCast (Ep. 21), the first question and answer style emergency medicine podcast. Listen and learn more.\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.roshreview.com\/blog\/ep-21-galeazzi-fractures-malnutrition-chest-tubes-central-retinal-artery-occlusion-boutonniere-deformity-anticonvulsant-hypersensitivity-syndrome\/\" \/>\n<meta property=\"og:site_name\" content=\"RoshReview.com\" \/>\n<meta property=\"article:published_time\" content=\"2017-04-05T16:17:13+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep21.png\" \/>\n\t<meta property=\"og:image:width\" content=\"517\" \/>\n\t<meta property=\"og:image:height\" content=\"346\" \/>\n\t<meta property=\"og:image:type\" content=\"image\/png\" \/>\n<meta name=\"author\" content=\"Nachi Gupta, M.D., Ph.D., and Megha Rajpal, M.D.\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Nachi Gupta, M.D., Ph.D., and Megha Rajpal, M.D.\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"6 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.roshreview.com\/blog\/ep-21-galeazzi-fractures-malnutrition-chest-tubes-central-retinal-artery-occlusion-boutonniere-deformity-anticonvulsant-hypersensitivity-syndrome\/\",\"url\":\"https:\/\/www.roshreview.com\/blog\/ep-21-galeazzi-fractures-malnutrition-chest-tubes-central-retinal-artery-occlusion-boutonniere-deformity-anticonvulsant-hypersensitivity-syndrome\/\",\"name\":\"Podcast Ep 21: Galeazzi Fractures, Malnutrition & More | RoshReview.com\",\"isPartOf\":{\"@id\":\"https:\/\/www.roshreview.com\/blog\/#website\"},\"primaryImageOfPage\":{\"@id\":\"https:\/\/www.roshreview.com\/blog\/ep-21-galeazzi-fractures-malnutrition-chest-tubes-central-retinal-artery-occlusion-boutonniere-deformity-anticonvulsant-hypersensitivity-syndrome\/#primaryimage\"},\"image\":{\"@id\":\"https:\/\/www.roshreview.com\/blog\/ep-21-galeazzi-fractures-malnutrition-chest-tubes-central-retinal-artery-occlusion-boutonniere-deformity-anticonvulsant-hypersensitivity-syndrome\/#primaryimage\"},\"thumbnailUrl\":\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep21.png\",\"datePublished\":\"2017-04-05T16:17:13+00:00\",\"author\":{\"@id\":\"https:\/\/www.roshreview.com\/blog\/#\/schema\/person\/a838e825547ab58f0be77d446d19338a\"},\"description\":\"Welcome to RoshCast (Ep. 21), the first question and answer style emergency medicine podcast. 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