PODCAST: EM Quick Hits 30 Scaphoid Fracture, Therapeutic Hypothermia, HEADS-ED, Pelvic Trauma, Kratom, Femoral Lines

Topics in this EM Quick Hits podcast

Arun Sayal on nuances for assessment of scaphoid fractures (0:52)

Justin Morgenstern on the TTM2 trial and temperature management after cardiac arrest (7:42)

Sarah Reid on HEADS-ED screening tool for pediatric mental health (12:48)

Andrew Petrosoniak on pelvic binders and fracture tips (18:54)

Michelle Klaiman on what you need to know about kratom (24:43)

Anand Swaminathan on why femoral lines have made a come back and procedural tips (30:09)

Scaphoid fractures: nuances of assessment

Epidemiology is important for pre-test probability assessment

  • carpal injuries represent 20% of wrist injuries in the ED, of which 70% are scaphoid fractures
  • Less likely in children < 15-years-old and adults > 50-years-old
  • 20-30% of fractures are occult on initial X-rays

Diagnostic usefulness of the 3 physical exam maneuvers for scaphoid fractures

  • Snuff box tenderness
    • Poor specificity: many patients have physiologic snuff box tenderness at baseline; tip – palpate for asymmetric snuff box tenderness (i.e. check the contralateral wrist)
    • Examination should be done with the wrist in ulnar deviation to expose the scaphoid

scaphoid snuffbox ulnar deviation

Palpate the snuffbox with the wrist in ulnar deviation to expose the scaphoid bone and compare to the contralateral wrist

  • Palmar scaphoid palpation –  tenderness at base of the thenar eminence over the palpable scaphoid tubercle with the wrist in radial deviation

palmar scaphoid in radial deviation

Palmar location of scaphoid bone brought out by putting the wrist in radial deviation

  • Axial thumb loading of 1st metacarpal to compress the scaphoid is less specific in elderly as a positive test is more likely indicative of CMC osteoarthritis rather than scaphoid fracture
  • 3 of 3 portends a 70-90% likelihood of a scaphoid fracture (30-50% likelihood if 1/3).
  • Consider adding dedicated scaphoid view if any one of the 3 exam maneuvers are positive
  • Clamp sign has a pooled +LR of 8.6 for a scaphoid fracture. Ask the patient exactly where it hurts the most. If they place their thumb and index finger like a clamp on the volar and dorsal aspects of the base of the thumb, they have a positive Clamp Sign

clamp sign scaphoid fracture

The Clamp Sign has high positive likelihood ratio for the diagnosis of scaphoid fracture. Ask the patient to show you where the pain is the greatest. Grasping their scaphoid with their thumb and index finger is a positive Clamp Sign.

Temperature management after cardiac arrest – the TTM2 trial

Question: does targeted hypothermia (vs. controlled normothermia) impact all-cause mortality in patients with a coma following out-of-hospital cardiac arrest?

Design: international multi-center RCT of 1,900 patients randomized to a hypothermia (targeted temperature of 33°C) or controlled normothermia (targeted temperature of ≤ 37.5°C)

Primary outcome: all-cause mortality at 6 months


  • No difference in all-cause mortality at 6 months
  • No difference in secondary outcomes including functional and neurologic outcomes
  • Adverse events higher in hypothermia group, mostly dysrhythmias

Problems with this study: there was no true control group i.e., group that had no temperature control, and so this study does not address the utility of fever control. There is no conclusive evidence that fever control improves outcomes, but many clinicians still use this hypothesis in their practice.


  • Therapeutic hypothermia (33°C) in patients with coma following an out-of-hospital cardiac arrest does not improve mortality, functional or neurologic outcomes and are associated with more adverse events
  • Fever control in these patients is a reasonable hypothesis but there is no evidence to support this practice either

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