You evaluate an elderly female who has tripped and fallen at home. She denies any chest pain, shortness of breath or other acute medical symptoms and was well until the event. alt

The paramedics call-in a trauma alert on a 45 year old who ran his 4-wheeler into a tree. He was wearing a helmet, and his only obvious injury is an open fractured distal tib-fib on the right. They splint his fracture, give him morphine 8mg IV per protocol, and apply diesel fuel to the rest of the situation. 

A 42-year-old male comes to the emergency department with left lower quadrant and suprapubic abdominal pain which has become progressively worse over the prior two days. The day of presentation he noted mild chills prompting him to come in for evaluation. 
Wet Readings
Wet Readings
Is this man’s stomach pain a hot gallbladder?
altA 31-year-old female without significant past medical history presents to the emergency department complaining of worsening shortness of breath which began three days ago. 
 A 64-year-old Hispanic female presents to your ED with a complaint of pain in the left lower extremity and difficulty walking. She states that she fell two days ago and since then noted swelling and pain in her lower leg and ankle. It has progressively worsened since the injury and is not relieved by over-the-counter analgesics. She noticed blisters beginning to develop on her leg one day after the injury. Upon further inquiry, the patient states that she had a mechanical fall after stepping on a loose floor board at home and fell through the carpet. She denies any injury to the hips or pelvis and has no complaints of pain in the contralateral extremity. Her medical history is only significant for hypertension and she has no surgical history.
Obvious cholecystitis?
Ignore the obvious and work the problem
altThis case illustrates a common clinical pathology in children by a not so common mechanism, especially after the institution of legislation against the use of infant walkers. Also, it is a reminder to emergency physicians to evaluate for non-accidental trauma when seeing injuries in a child who is not yet mobile.

Mark Schnellinger, MD
Manu Madhok, MD, MPH
Childrens Hospital of Minnesota

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