I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.
You can find more things on the FRCEM on this site here
(Featured image: Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org. From the case rID: 6359)
Give me a broad differential
- trauma
- remember NAI
- hip
- septic joint
- osteo
- perthes
- SUFE
- Still’s
- HSP
- Rheumatic Fever
- malignancy
- leukemia
- soft tissue tumours eg ewings
- sickle cell
- referred
- discitis
- spinal osteo the biggies
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How do you investigate it?
- there are lots of potential variations on this and no national UK guidance i could find
- reasonable to manage well appearing kids with some NSAID and review
- xray the sore, swollen bit if you can find it
- remember the hips if you can’t find it
- WCC/CRP and ESR are the blood tests to consider
- USS useful for hip effusion
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Tell me about Perthes
- aseptic necrosis of upper femoral epiphysis
- 3-10 yrs
- M:F, 4:1
- grouped with the other osteochodritites
- kohler’s – age 3-5, navicular
- keinbocks – lunate
- freiberg’s – 2nd MT
- scheurmann’s – vertebral
- xray changes
- 1) inc joint space medially
- 2) appears sclerotic
- 3) flattening
- 4) rarefaction and cysts
- younger age at onset and earlier stage on xray predict better outcomes
- note if you did an USS don’t expect to see fluid with this one
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Tell me about SUFE
- pubertal
- M:F, 3:1
- two body types
- obese and sexually under developed
- thin rapidly growing adolescent with normal sexual development
- often referred to knee
- this is the importance of your frog leg
- Trethowan’s sign (not thockmorten…)
- normally line across sup border of fem neck should go through the epiphysis, if a slip then this line doesn’t touch the epiphysis
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What are some traction apophysitides
- Osgood-Schlatter
- boys 10-15
- knee pain after exercise
- tibial tuberosity can look funny on xray
- Johannsen-Sinding-Larsen
- lower pole patella
- distinguish from osgood
- Sever’s
- calcaneal achilles
- 8-14
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