POTD: No One's Going Home!

Just kidding, Maimo Fam, our patients will be going home, but first, we need to find out where they're going! Are they going to Waterford on the Bay or Garden of Eden? Which one of them is an adult home again? Wait, what's an adult home??

This POTD will hopefully answer those burning questions. This discussion was requested after a conversation of the differences between group home vs. adult home vs. assisted living facility.

Group Home

A group home is a private residence for children, adolescents, young adult men/women, adults, or seniors who either cannot live with their families or are diagnosed with chronic disabilities. Historically, the term "group home" referred to "shelters" housing residents who possess autism, intellectual disability, physical disability, or even multiple disabilities. Group home residents have residence coordinators and will usually come to the ED with an escort. Often times they will have family to make decisions for them.

Adult Home

Adult Homes provide long-term, non-medical residential services to adults who are substantially unable to live independently due to physical, mental, or other limitations associated with age or other factors. Residents of adult homes often have chronic psychiatric conditions. However, residents must not require the continual medical or nursing services provided in acute care hospitals, in-patient psychiatric facilities, skilled nursing homes, or other health related facilities, as Adult Care Facilities are not licensed to provide for such nursing or medical care.

Don't forget to contact the adult home coordinator prior to discharge.

Ex: Garden of Eden (also happens to be an assisted living facility!)

Assisted Living Facility

Assisted living provides long-term housing and care for seniors. Assisted living residents are generally active, but may need support with activities of daily living (ADLs), such as bathing, dressing, and using the toilet. Seniors in assisted living can expect personalized care, nutritious meals, a wide range of social activities to cater to a variety of interests, and a sense of community in a safe, residential setting.

Assisted living is for people who need help with daily care, but not as much help as a nursing home provides.

Ex: Waterford on the Bay, Signature Senior Living, Oceanview Manor

References:

https://www.aplaceformom.com/assisted-living

https://www.health.ny.gov/facilities/adult_care/

https://www.atthecrossroads.com/g/Group-Homes-For-Young-Adults/New-York-NY/

POTD: Listen, Frank, let's talk about Lisfranc Injuries

Background

Lisfranc ligament attaches 2nd metatarsal to medial cuneiform

2nd metatarsal is held in mortice created by the three cuneiform bones

Injury to 2nd metatarsal often results in dislocation of the other MTs

Dorsalis pedis may be injured in severe dislocation

Lisfranc Injury = any fracture or dislocation of the tarsal-metatarsal joint

Mechanism of Injury

MVAs, falls from height, and athletic injuries

Indirect rotational forces and axial load through hyper-plantarflexed forefoot

hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation

metatarsals displaced in dorsal/lateral direction

Clinical Features

Inability to bear weight (especially on tiptoe)

Tenderness over tarsometatarsal region

Pain with pronation and passive abduction of the midfoot

Ecchymosis of plantar section of midfoot is highly suggestive

Imaging

Obtain radiographs, which include AP, lateral, oblique, and weight bearing views.

AP: Medial margin of 2nd metatarsal base does not align with medial margin of 2nd cuneiform. Bony displacement 1mm or greater between bases of first and second metatarsals is considered unstable.

Oblique: Medial margin of 3rd metatarsal does not align with medial margin of 3rd cuneiform.

Lateral: 2nd metatarsal is higher than middle cuneiform (step-off).

If suspicion is high based on history and physical, you may want to consider obtaining further imaging in conjunction with your ortho consultants.

Treatment and Dispo

Sprains and non-displaced fractures:

Non-weightbearing splint with ortho follow up (most managed with cast x 6 weeks)

Posterior Ankle Splint

Displaced fractures:

Emergent ortho consult

When diagnosed appropriately, patients who undergo open reduction and internal fixation of fractures have superior outcomes to those with purely ligamentous injury

20% are missed on first presentation to ED, so keep this in mind the next time you see a patient with the chief complaint of foot pain!

References:

https://www.orthobullets.com/foot-and-ankle/7030/lisfranc-injury

Sherief, T et al. Lisfranc injury: How frequently does it get missed? And how can we improve? Injury: International Journal of the Care of the Injured 2007: 34; 856-860. PMID: 17214988

POTD: Hair Tourniquet

This POTD is inspired by a case I saw from the periphery while in the Peds ED. I'll be discussing hair tourniquets!

Toe-tourniquet syndrome, also called Hair-thread tourniquet syndrome (HTTS), is a rare and commonly misdiagnosed condition caused by hair or fiber wrapped around digits (fingers and toes), penis, or even clitoris. It usually affects infant and children. Prompt diagnosis is needed as ischemia can result.

This is a diagnosis often missed because the presentation is so vague. Often the only complaint is a crying and inconsolable infant. This is why the physical exam is so important! Redness and swelling distal to a constricting band is usually found, so check all of those digits and do a thorough genital exam.

Treatment includes early recognition of the condition and immediate release of constriction to prevent devastating complication in the form of digit loss or genital damage. Careful circumferential examination of affected part should be done as swelling and erythema, can mimic infection, so correlate clinically with the history. A hand held magnifying glass can be useful in circumstances where the diagnosis is not certain.

Simple removal with scissors or even an IV catheter needle could do the trick. If the skin is intact, hair removal agents, such as Nair, can be used. Apply the agent on the area for about 8 minutes and then rub the agent and hair off. If all else has failed, consider a dorsal slit for cases where skin is broken and tourniquet is too tight for other methods.

With successful removal of the hair tourniquet, patients are discharged home with appropriate follow up.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393137/

https://www.annemergmed.com/article/S0196-0644(15)01574-7/fulltext

https://wikem.org/wiki/Hair_tourniquets#cite_ref-1